It is expected that the health risks of climate change will increase globally, with increases in morbidity and mortality from selected climate-sensitive health outcomes, putting additional pressures on health systems [1
]. The effectiveness of adaptation is influenced by a country’s physical location and exposure to climate shocks, levels of socioeconomic development, and healthcare capacity to prepare for and manage climate-related shocks [3
]. Tailoring effective adaptation measures requires a clear understanding of which factors led to today’s preparedness to manage climate change. Researchers have been urged to pay more attention to the role of the nation state in climate governance, as these actors have the legitimacy and resources to develop long-term visions, stimulate and oversee local approaches, and carry forward adaptation programs, e.g., [4
]. In their analysis of health adaptation initiatives in ten Organization for Economic Co-operation and Development (OECD) countries, Austin et al. concluded that national governments play a key role in health adaptation to climate change, but there are competing views on what responsibilities and obligations this will—or should—include [5
]. One view suggests increasing investments in existing public health infrastructure to manage the projected health risks [6
]. The second argues climate change will likely affect health by, for instance, destabilising supporting systems or threatening infrastructure, thus necessitating new and innovative responses. Suggested factors for successful adaptation include adopting legislation, ensuring interdepartmental coordination, and increasing self-governance [7
]. We take an in-depth look at health and rescue systems in Estonia, because they will play a key role in climate adaptation policies in connection with the EU climate change strategy [10
Informed by the research on risk governance [11
], we analyse the health and rescue system as a control system for achieving policy goals; assess factors shaping those goals; and assess the factors shaping the process of information-gathering and implementation of protective measures, such as early warning systems or emergency preparations. We examine the extent to which outside (e.g., issue salience) and inside (e.g., institutional capacities and rules) drivers of the health systems shape the success of climate adaptation. We apply the World Health Organization’s Operational Framework for Building Climate Resilient Health Systems [13
] to understand how the quality of leadership and governance, health workforce, health information systems, medical technologies, service delivery, and climate and health financing shape the quality, efficiency, equity, accountability, and resilience of the health systems [14
1.1. Climate Change Adaptation of Health Systems
We adopt a case-study framework of adaptation of health systems (Figure 1
). For analytic purposes, the framework distinguishes between the processes of elaborating policy programmes, monitoring, and information-gathering, and enforcing protective measures. The framework recognises significant overlaps and feedback loops between these responsibilities of the Estonian health system. Effective and timely responses depend on effective policies, strategies, and action plans
crafted by political leaders to manage climate-sensitive health outcomes. The WHO Operational Framework specifies that in order to continuously deliver health services throughout climate-related events, governments should modify emergency management plans and incorporate up-to-date risk assessments. In line with the European Union’s climate change adaptation strategy [15
], most European countries have developed national strategies, but few countries have implemented regulations and operational plans for authorities and healthcare systems to manage health-related issues.
Monitoring and gathering information
of health and health system conditions provides information for timely responses and behaviour change, but also for setting new goals and amending legislation. The WHO Operational Framework [13
] identifies three key areas that health information systems must develop: vulnerability, capacity, and adaptation assessments; risk monitoring; and climate and health research. Risk monitoring systems provide timely, detailed information on current and future environmental conditions that may affect health and the ability of health systems to provide services. In the context of climate change, hurdles for new interventions may arise in the form of evidence provision; climate will continue to change over coming decades, with uncertainties associated with the rate and magnitude [16
]. The tendency of turning a “blind eye” towards policy problems by limiting investments in surveillance and monitoring may work to maintain the status quo in state investments [18
As for timely responses and protective measures
, monitoring systems coupled with communication networks (early warning systems) can be designed to alert members of the public when environmental hazards may affect their health. However, existing health safety programs excessively focus on providing information [19
] without considering the need to change motivation and supportive infrastructure, living arrangements, and skills. For example, climate change can affect the ability of healthcare systems to provide services during extreme weather events because of infrastructure damage and medical supply disruptions [13
1.2. Factors Influencing Adaptation of Policy Programmes, Monitoring Systems, and Response Measures
Effectively adapting to the health risks of climate change includes internal factors related to administering health systems, such as management structure and capability, and external factors, including the pressure of interest groups and the public. The internal functioning
of health systems is often characterised by administrative cultures of reactivity and lack of long-term future orientation. The administrative focus is tightly related to the risk calculus that politicians make; this includes issues such as the visibility of the problem (which may be obvious to experts but far less so to the general public and politicians) and the avoidability of blame (for events that lead to damage) [20
]. By contrast, the notion of institutional adaptive capacity [22
] highlights the proactive provision of means and information to enable social actors to anticipate possible futures and take preventive measures.
Administrative capacity is the health system’s economic aptitude, technical preparedness, and competence and sufficiency of human resources; these factors may influence the development and application of adaptation policy [23
]. At lower level administrative units, larger municipalities are likely to have more human and financial resources to direct to adaptation [24
]. Maintaining a healthy and effective practitioner workforce, products, and technologies are critical challenges for health systems [13
]. Beyond human and financial resources, institutions should have the authority to generate political and legal incentives for actors to change [26
The administrative architecture is crucial in the design of adaptation policy, as multilevel institutions and networks are needed for the process to be successful [27
]. Developing effective adaptation plans requires coordination and collaboration between health ministries and other government agencies and non-governmental partners, to ensure that the actions undertaken foster positive health outcomes [13
]. Policy coherence literatures (see Tosun and Lang, 2017 [28
]) highlight the demanding task of integrating institutions, particularly in cases with an increasing number of affected interests, such as health [29
] or security [30
The most obvious contextual driver
of political and administrative action is the effect of extreme events spurring increased awareness and policy innovation [18
]. In general, climate change is difficult to understand and psychologically distant for lay people and political and administrative actors [31
]. However, according to the policy-window hypothesis, following a disaster, the political climate may be conducive to legal, economic, and social change that can begin to reduce structural vulnerabilities [32
Based on strong interests, non-governmental organisations, entrepreneurs, or the scientific community can influence health risk governance [12
]. Robust climate and health research agendas should expand and improve the quality of knowledge [33
]. However, the scarcity of scientific evidence of the emergence of climate change-related health impacts may challenge the ability to develop effective adaptation options [34
In countries of the former Soviet Union, the role of non-governmental organisations in developing and applying regulatory regimes has been modest [18
]. This may change as national groups advocating a certain policy or action gain prominence when an issue is placed on the political agenda and reaches a certain level of salience [35
International organisations pose crucial pressures; the adoption of climate policies in the OECD countries was influenced by learning from international organisations [36
]. The issue of climate change entered the political agendas of Central and Eastern European countries through the EU [37
]. Exemplary neighbouring states are urging other EU countries to tighten their mitigation policies [36
In the context of climate change, this study takes a comprehensive look at external pressures and factors characterising the internal working of the Estonian health system. We first present empirical data and methods that are used to validate our expectations. We then discuss background information about Estonia’s health systems’ adaptation to climate change. In subsequent sections, we discuss how the dominant ideas, administrative structures and capacities, and windows of opportunity have shaped the current situation with respect to adaptation politics.
Estonia lies in the North-Eastern corner of Europe. Out of a population of 1.3 million, 35.5% are nationalities other than Estonian, including Russians (25%). One million people (77.2% of the population) live in urban areas [40
]. Income disparities are relatively large at 33.2% [40
]. The health inequalities among different age, education, and ethnicity groups are considerably larger in Estonia than in other Nordic countries [41
]. For example, life expectancy among Estonians is 78.5 years, and non-Estonians 76.5, and total life expectancy is 77.6 years in Estonia, compared with 81.1 years in Finland [42
For analysing the health systems’ amenability to internal and contextual pressures, Estonian legislative acts, directives, strategic documents, such as activity plans, and their implementation were examined. In addition, 21 semi-structured interviews were conducted with key experts connected to health system adaptation in Estonia, ranging from policy designers to officials to scientists to social workers (Appendix A
). The interviews clarified the expert’s observations and experiences with the functioning of the Estonian health system and the actors and processes shaping its effectiveness. The interviews addressed the questions of the capability of the health and rescue system, operability of implemented measures, and the importance of various factors in shaping health system adaptation (Appendix B
). The interviews were conducted in the spring of 2015 when compiling an adaptation strategy for the reducing the health risks of climate change and when health impact assessments were in their infancy [43
To address public salience as an external driver of adaptation governance, we use a survey on environmental health risk perception and coping conducted in Estonia in 2015 of persons aged 18–75 years, stratified by age, sex, and geographical location [44
]. The survey invited 2207 participants (administered by IBP Saar Poll), of which 1000 agreed (45.3% response rate). We used a semi-structured questionnaire constructed to assess climate change-related issues, such as perceived exposure to extreme weather events, demand for state support for coping with extreme events, beliefs about state institutions’ efficacy in taking care of the healthfulness of the environment, and concerns about health risks from the environment (Appendix C
). Additionally, the instrument had entries for respondents’ demographic data and self-rated health status.
We used a logistic regression analysis to estimate which factors were associated with perceived needs for measures for coping with the health risks of climate change. For statistical modelling of covariates of perceived need, we collapsed perceived need ratings into dichotomous groups by combining the answers high to total agreement (scores 4–5) into a group perceiving need, and the other categories as not. We recoded worry about health risk to self and family arising from the environment, as scores 1 and 2 = group 1, score 3 = group 2, and scores 4 and 5 = group 3.
Our research clarified the factors determining the preparedness of the health system in Estonia to manage the health risks of climate change. The study was conducted in 2015, when health adaptation had not been legally defined. The material analysed was used as background material for compiling the strategy “Climate Change Adaption Development Plan until 2030” that was ratified by the Estonian parliament in 2017 [70
]. A “Climate Change Adaption Development Plan’s Action Plan for 2017–2020” was subsequently agreed upon. However, the resources dedicated for the action plan were a magnitude smaller than what was proposed [71
]. Therefore, many of the problems raised in the study remain to be addressed. Our analyses take an in-depth look at one country, Estonia. The lessons learned could be of relevance for other countries with similar Eastern European backgrounds. In some Eastern European countries (e.g., Poland), climate change adaptation and mitigation are taken seriously at the city level [25
]. However, Eastern European countries, including Estonia, fall far behind Finland, Sweden, and the United Kingdom in adaptation planning and implementation.
The policy innovation literature, e.g., [4
] offers some clues as to the circumstances under which adaptation policies emerge, e.g., bringing out the role of leadership and the state’s participation in international organisations. However, the literature stops short in giving an integrated look at the drivers behind implementation, monitoring, and protective responses. We took a broader look at the health systems functioning and the variety of drivers shaping its effectiveness and equality in provision. An in-depth case study allowed exploration of the mechanisms behind the adoption and implementation of adaptation policies, including the broader perspective of health systems, particularly prevention, healthcare provision, and rescue services.
The WHO Operational Framework foresees that for effective policymaking activities, policymakers and other stakeholders require accurate, timely information on health and health system conditions. However, up until the initiation of baseline studies for a climate adaptation strategy pursuant to the EU Directive [15
], there had been no studies on climate change and related health systems functioning. Our analyses confirm the findings by Massey et al. [23
] that external drivers, primarily, the centrality of EU is required for the diffusion of adaptation policies across Europe. EU institutions are important driving forces for gathering information, especially in improving monitoring and early warning systems.
It has been argued that the “EU values” on climate change are not internalised by the political actors in Central and Eastern Europe [25
]. The analyses in this paper highlight several key impediments for why health systems have not fully adopted these ideas. One is the style of regulation
. The market liberal state approach characteristic of environmental health governance in Estonia can dissociate responsibilities with the “lean state” rhetoric [18
]. The overruling perspective among policymakers is that if climate change occurs at all, then people should be able to cope with the long-term effects by themselves. Such a perspective can be explained by limited economic capacity and the lack of evidence. This dissociation of responsibilities is understandable as the evidence pointing to the need for intervention is scarce, and longer-term planning based on projections of the health risks of climate change is limited. The tendency of turning a “blind eye” towards policy problems by limiting investments in monitoring and inspection also occur in other environmental health issues [18
]. We may assume that health systems in other small countries with dispersed human, financial, and political resources may lack the resources necessary for adaptive capacity [22
] to deal with what is still often considered as an avant-garde issue of climate change risks.
Even if the capability to cope during acute situations exists, there is no certainty as to the extent to which family physicians and hospitals operating under the private law would be ready for extreme events. Maintaining an informed and effective practitioner workforce is a critical challenge for health systems grappling with extreme events [13
], however, no contingency plan has been elaborated for hospitals. Limited preparation and the state approach of minimal interference has important implications for the safety of the most vulnerable population groups, including elderly and minority groups.
Our results highlight the significance of the regulatory architecture and the related allocation of responsibilities
. Climate change-related health risks are highly cross-sectoral, which means that other state departments are expected to assume primary responsibility. In extreme weather conditions, healthcare systems and rescue services will indeed cope within the limits of their competences, but in case of more complex issues, prevention and timely responses are inhibited by the lack of cooperation between rescue and social services, and healthcare providers. Also, for information-gathering, monitoring of some parameters or vulnerable groups is organised separately, fragmented between institutions. Fragmentation inhibits the integrated assessment of climate change-related health and related risks and vulnerabilities. Furthermore, lack of coordination and integration impedes accessing a range of possible solutions. The process of mainstreaming a policy issue (also called policy integration [73
]) through the integration of adaptation policy and measures into ongoing national sectorial planning is expected to increase policy coherence, minimise contradictory policies, and capture the opportunities for synergistic efforts in terms of increased adaptive capacity [74
]. However, developing cross-sectorial policy goals becomes more demanding with an increase in the number of affected institutions and interests [75
]. A solution addressing the institutional and organisational dimension of the problem would be to appoint a responsible institution that could facilitate policy integration in-between existing policy pillars. Attempts at mainstreaming are also more likely when the issue receives political attention [24
]. The EU Climate Adaptation Strategy has been an important force to increase the political salience of the topic. However, this has yet to translate into actual better coordination between the institutions.
Our analysis shows the societal and institutional silencing
of the health risks of climate change. Institutional responses constitute important influences on people’s perceptions [77
], and the implementation of adaptation measures require some degree of demand from citizens [78
]. The low level of worries and attention to climate change adaptation measures can be explained through the limited “pool of worries” hypothesis, and the tendencies of attenuation of risk in countries preoccupied with socioeconomic instability. With the increase in income levels, the East of Europe countries are expected to increase their concern with respect to climate change [80
]. Although there is an increase in levels of concern in Eastern member states, including Estonia, instead of these countries “catching up” with the levels of concern of southern and northern EU countries, the Eurobarometer studies show an increase in the relative difference between the average levels of concern in these groups of countries [68
Low level of engagement with adaptation has been attributed to a lack of knowledge of climate change and related adaptation issues [82
]. Although experience with weather-related phenomena may give rise to a perceived need for adaptation action [84
], Estonia has yet to experience any major weather extremes (except for a major heatwave in 2010 [87
]. This may have impeded awareness of the risks amongst the public. The low demand for health adaptation may also be explained by the general population being used to relatively extreme weather over four seasons (a few hot weeks are warmly welcomed). Further, the geographical size of the country may play a role, as the small size of the country decreases the chances of anything happening, leaving an impression that climate-related events that happen in other, even close-by countries, do not affect our safety and wellbeing. It has been argued that extraordinary storms and heatwaves can result in a focus on the current emergency, leaving the long-standing risks unattended [20
]. However, the Estonian case indicates that increased experience with attention-grabbing extreme events in the northeastern parts of Europe could bring to the fore the need to consider long-term climate trends, and risks for health and health systems.
The occurrence of extreme weather events, coupled with research projecting that these are likely to increase in frequency and severity, resulting in increasing costs in the future, motivates richer states [23
]. In the case of Estonia, an upper-middle income country, the lack of public and political salience means research of climate change-related health effects is less of a priority. The associated lack of evidence, in turn, may inhibit raising public awareness and efforts to establish health adaptation goals and implement policies and programs, including increasing individual and community-based capacities to respond to emergencies. Recent projections indicate substantial increases in summer temperatures by the end of the century over central and Eastern Europe [88
], along with projected increases in pollution levels (near-surface ozone and aerosol particles) [89
]. Health risks will increase under these projections, unless proactive adaptation is undertaken.
Ethnic minorities (mainly Russian-speaking) and city-dwellers are more worried about climate change, and express higher demand for protective measures. Their concerns can be explained by their social status, and the perceived level of control a person has over one’s physical or psychological wellbeing. As shown also in the literature on risk perception among minority groups [90
], the demand for measures is high among individuals with weakened positions, and who, in general, may have restricted ability to influence decision-making. This has further implications for managing the vulnerability of minority groups. Their perceived inhibited access to informal and institutional support may be an indication of actual vulnerability, but also a lack of awareness of support networks. As a novel finding, respondents in urban areas expressed higher demand for measures for coping with the health risks of climate change. A possible explanation for the urban dwellers’ higher demand for protective measures could be attributed to their dependence on urban expert systems and infrastructures that may make city dwellers feel more vulnerable, with a general sense of higher exposure to extreme weather events. In rural areas, individuals have lower expectations from the state, being situated further away from expert systems; they have maintained skills to cope with current extreme weather events, but may not be prepared for future, more extreme events.
The study shows the significance of the EU pressures for aligning the health systems of a small country, like Estonia, with the climate adaptation goals of building resilience to future increases in, e.g., projected storminess and length of heatwaves. However, the effect of these external pressures remains short-lived, when the political salience of climate change and the related political will is low to mainstream climate change into policies, and to invest scarce resources in adaptation policy programmes, monitoring, and protective responses. Although efforts are being made in emergency preparedness and rescue, which, as a co-benefit, increase the ability to cope with the health risks of climate-related extreme events, the state has limited avenues for pressuring the private domains of primary care and hospitals. There are significant opportunities to gain synergistic benefits from conducting risk and vulnerability analyses, and from building community resilience through mainstreaming climate change over related policy fields, including rescue services, health, environment, social care, and even education. In a situation where there is lack of issue ownership, policy integration and mainstreaming could be facilitated by appointing a responsible institution. Institutional responses resonate with people’s perception and the demand for adaptation measures. As characteristic of a small health system, the shortage of regionally specific scientific assessments and lack of pressure from other organised interest groups, attenuate the social and political urgency for adaptation. Nevertheless, growing experience with extreme weather events, particularly among increasing urban and minority populations who are detached from traditional coping strategies, may increase demand for the provision of state support for health adaptation.