Effectiveness of greenhouse gas mitigation intervention for health-care systems: a systematic review

159Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Introduction In the absence of actions to rapidly reduce global greenhouse gas emissions, climate change is predicted to be the biggest threat to human health in the 21st century. Direct and indi- rect health effects from climate change include exposure to extreme weather, undernutrition, the spread of vector-borne diseases, lack of access to clean water, and mental health ef- fects.1 Health-care systems are facing the challenge of treat- ing these impacts, but they also emit about 4.4% of global greenhouse gas emissions with projected increases in emis- sions.2,3 Since the United Nations Framework Convention on Climate Change 26th Conference of Parties in 2021 (UNFCCC COP26), 75(54 low- and middle-income) countries have committed to transitioning to sustainable, low-carbon health systems, with 29 (22 low- and middle-income) countries aim- ing to reach net-zero emissions in their health-care systems.4,5 Health-care systems in low- and middle-income coun- tries emit lower per capita greenhouse gas emissions com- pared to those in high-income countries,2,3 but as health- care systems in many low- and middle-income countries advance, an increase in emissions is likely unless steps are taken to identify, measure and control them. Low- and middle-income countries are also predicted to experience the harmful effects of climate change with greater intensity and at an earlier stage due to their geographical location, exposure and vulnerability, while being less equipped to handle these effects due to a shortage of resources to cope and recover.6,7 Any adaptation actions undertaken by health-care systems should not exacerbate the health sec- tor's greenhouse gas emissions, creating negative feedback loops and locking them into higher emission trajectories. To fulfil the commitments undertaken at, and since, COP26, it is necessary to identify evidence-based strate- gies for reducing the greenhouse gas emissions of health- care systems in low- and middle-income countries.8 We undertook a systematic review to identify modelled and implemented greenhouse gas mitigation interventions and their relationship with adaptation, applicable within the context of low- and middle-income countries, to provide evidence on which interventions are most feasible to imple- ment and where actions can be scaled to provide significant reductions in emissions within health-care facilities and across the sector. Methods We followed a protocol published on 4 August 20229 following the Preferred reporting items for systematic review and meta-analysis protocols10 checklist (online repository).11 The protocol underwent one methodologi- cal amendment, namely the removal of the Joanna Briggs Institute Critical Appraisal Tools for evaluation, as they were not relevant to the types of interventions we anal- ysed.12 We searched the database Ovid MEDLINE®, Ovid Embase®, Global Health, Web of Science, Africa-Wide Information, LILACS, Global Index Medicus, ELDIS, SCO- PUS, AfricaPortal and GreenFILE on 17 March 2023. We predetermined the inclusion and exclusion criteria, which are detailed in Box 1. Research a Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT, England. b Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt. c Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, Kingdom of the Netherlands. d Bolan Medical College, Quetta, Pakistan. Correspondence to Iris Martine Blom (email: iris.blom@ lshtm .ac .uk). (Submitted: 27 June 2023 – Revised version received: 9 October 2023 – Accepted: 6 November 2023 – Published online: 31 January 2023 ) Objective To identify evidence-based interventions that reduce greenhouse gas emissions in health-care systems in low- and middle- income countries and explore potential synergies from these interventions that aid climate change adaptation while mitigating emissions. Methods We systematically searched 11 electronic databases for articles published between 1990 and March 2023. We assessed risk of bias in each article and graded the quality of evidence across interventions in health-care operations, energy and supply chains. Findings After screening 25 570 unique records, we included 22 studies published between 2000 and 2022 from 11 countries across six World Health Organization regions. Identified articles reported on interventions spanning six different sources of emissions, namely energy, waste, heating and cooling, operations and logistics, building design and anaesthetic gases; all of which demonstrated potential for significant greenhouse gas emission reductions, cost savings and positive health impacts. The overall quality of evidence is low because of wide variation in greenhouse gas emissions measuring and reporting. Conclusion There are opportunities to reduce the greenhouse gas emissions from health-care systems in low- and middle-income countries, but gaps in evidence were identified across sources of emissions, such as the supply chain, as well as a lack of consideration of interactions with adaptation goals. As efforts to mitigate greenhouse gas intensify, rigorous monitoring, evaluation and reporting of these efforts are needed. Such actions will contribute to a strong evidence base that can inform policy-makers across contexts. Effectiveness of greenhouse gas mitigation intervention for health-care systems: a systematic review Iris Martine Blom,a Mohamed Eissa,b Juliette Claudine Mattijsen,c Hamaiyal Sana,d Andy Hainesa & Sarah Whitmeea Researc Greenhouse gas mitigation interventions for health-care systems 160 Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Research Search strategy Our search strategy consisted of three main elements: (i) the health-care system; (ii) greenhouse gases; and (iii) low- and middle-income coun- tries (Box 2 and online repository).9,15 To further structure our strategy, we devised a conceptual theory of change framework. We used approaches out- lined by the United Nations Sustainable Development Group Latin America and the Caribbean and the New Phi- lanthropy Capital and insights from a previous publication to develop this framework.16,17 The framework is de- fined in (Box 3; available at: https:// www .who .int/ publications/ journals/ bulletin/ ) and detailed descriptions of each section can be found in our online repository.15 Selection process and data extraction We uploaded records using Rayyan QCRI software (Rayyan, Cambridge, United States of America), and the aforementioned inclusion and exclusion criteria were applied throughout the screening process. Following published efficiency guidelines,18 we removed duplicates, screened titles and analysed abstracts and full texts against eligibil- ity criteria using Rayyan QCRI. Two reviewers performed each step sepa- rately, after which any disagreements were discussed. If no consensus was reached, a third author was consulted for resolution. Two reviewers indepen- dently extracted all relevant data from eligible articles using a pre-tested form with detailed instructions (Box 4). This extracted data was used to generate a 100-word or less summary on the ex- traction sheet. We assessed risk of bias using spe- cifically designed questions intended to be applicable across different study types using a simple judgement of low risk, high risk or unclear risk on different axes as endorsed by the Cochrane Col- laboration.42 Independent assessments were made by at least two authors. We assessed the overall strength of evidence resulting from article synthesis using the Grading of recommendations assessment, development, and evalua- tion (GRADE) approach. The collated evidence was graded using four differ- ent categories: (i) very low (we believe the true effect is probably very different from the estimated effect); (ii) low (we believe the true effect might be very different from the estimated effect); (iii) moderate (we believe that the true effect is probably close to the estimated effect); or (iv) high (we are confident that the true effect is similar to the es- timated effect).43 We used GRADEpro Guideline Development Tool (McMaster University and Evidence Prime, Hamil- ton, Canada) for the analysis. Results Our search yielded 25 570 records. After removing duplicates and screening the titles, abstracts and full texts, 22 articles met the inclusion criteria (Fig. 1).20–41 Box 1. Inclusion criteria for articles on greenhouse gas mitigation interventions for health-care systems Publication types Peer-reviewed primary research including analytical cross-sectional studies, case-control studies, case reports, cohort studies, diagnostic test accuracy studies, and randomized controlled trials. We excluded other types of publications, such as protocols, guidelines, (systematic) reviews, perspectives, commentaries or editorials. We screened relevant reviews for primary research references. Languages No restriction. Context Findings of research in one or more low- and middle-income countries. Topic Any implemented or modelled greenhouse gas mitigation intervention across health-care operations, energy and supply chains. Outcome Reporting a quantified change in greenhouse gas emissions from the intervention. Timeline Published between 1990 and 17 March 2023. Year 1990 was chosen as a starting point for the inclusion of articles, as a significant number of publications supporting a connection between climate change and health started to appear in the early 1990s.13,14 Box 2. Search strategy, search line and content of search parameters to identify articles on greenhouse gas mitigation interventions for health-care systems 1: (netzero or net zero).mp. 2: carbon footprint/ 3: greenhouse effect/ 4: exp climate change/ 5: (carbon or CO2 or methane or CH4 or nitrous oxide or N2O or hydrofluorocarbon* or HFC* or perfluorocarbon* or PFC* or F-gas or fluorinated gas or sulfur hexafluoride or SF6 or nitrogen trifluoride or NF3 or emission* or greenhouse or GHG or climate change* or global warming or footprint or eco-friendly or climate friendly or environment* friendly or eco-efficient or environment* responsible or environment* sound or energy-efficient or energy-saving or green initiative* or environmental impact or short-lived climate pollutant or black carbon).mp. 6: (environment* and sustainable*).mp. 7: 1 or 2 or 3 or 4 or 5 or 6 8: exp “delivery of healthcare”/ 9: exp health facilities/ 10: (health system* or health care or healthcare or health sector or health supply chain* or health service* or delivery of health or health delivery or health facility* or health cent* or hospital or hospitals or clinic or clinics or emergency department* or operating* room* or operating* theatre* or patient care or ward* or urgent care or primary care or secondary care or tertiary care or quaternary care or telemedicine or medical cent* or diagnostic care or rehabilitative care or preventative care or palliative care or home care).mp. 11: 8 or 9 or 10 12: 7 and 11 304: or/13–303 [ALL LOW AND MIDDLE-INCOME COUNTRIES (expert search)] 305: 12 and 304 306: limit 305 to yr = ”1990–2023” Research 161Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Greenhouse gas mitigation interventions for health-care systems The 22 studies were published between 2000 and 2022, with 77% (17) of studies published between 2016 and 2022, and 36% (eight studies) between 2020 and 2022. They cover 11 countries across all World Health Organization (WHO) regions, primarily in the Western Pacific Region (seven studies) and South-East Asia Region (seven studies). India is the most-reported country (six studies; Fig. 2). Countries range from lower- to upper-middle-income countries, as per World Bank classification, with no low- income countries represented.44 Study settings vary from regional systems to urban areas, hospitals and rural centres (Table 1). Interventions Of the selected articles, we identified six primary intervention areas: energy (10 studies); waste (eight studies); heating and cooling (one study); operations and logistics (one study);building design (one study); and anaesthetic gases (one study). All articles detailed implemen- tation; 14 discussed costs; 13 reported health effects; and one considered ad- aptation to the effects of climate change. Twenty articles included data on car- bon dioxide reduction whereas only two articles reported on other greenhouse gases or pollutants (Table 2). For one ar- ticle, we could only extract percent reduc- tion of emissions20 and for five others no percentage could be calculated as original emissions were not provided.21,26,31,33,40 Three articles24,38,40 only reported de- creases in electricity usage, which was converted to carbon dioxide equivalent using the national grid emission fac- tor.45,46 Two articles24,27 included a 100% reduction of carbon dioxide emissions and in this case the supply chain, instal- lation of the system and relevant upkeep were not considered. Three articles indi- cated more than 100% reduction due to zero-emission electricity generation and selling the surplus.28,32,38 The intervention areas of energy and waste are outlined below, and the other four areas are de- scribed in Box 5. Energy interventions We identified reports on hybrid en- ergy systems using a combination of non-renewable and renewable energy sources20–22,25,26,28,29 or fully renewable sources;23,24,27 achieving carbon diox- ide emission reductions of 25%–233% as compared to alternative scenarios (Table 2) where the reductions higher than 100% are attributed to surplus elec- tricity generation exported to the grid. All reported energy systems featured solar photovoltaic electricity genera- tion paired with various other sources, such as wind or diesel. Greenhouse gas emissions from production and instal- lation were generally not considered, and no unintended consequences were reported. One article compared legal contexts and concluded that flexibility to sell or export electricity to the grid maximizes annual carbon dioxide emis- sion savings.28 Implementation We found that all study authors rec- ognized hybrid energy systems as acceptable interventions when consid- ering various factors such as electric- ity generation, environmental impact and economic feasibility. Photovoltaic electricity generation was also found to be environmentally, technically and economically feasible.20–22,28 The authors of two studies noted that these energy forms are scalable in rural health-care facilities in disparate geographical locations provided that lo- cal energy costs and climate parameters are considered during the pre-planning stages.20,23–25,28Scalability could extend to commercial buildings and agricultural industries as well.21,27 Initial capital costs and access to sufficient finance may act as a barrier to implementation of hybrid energy systems, but hybrid energy systems Box 4. Data extracted for each article identified in the systematic review on greenhouse gas mitigation interventions for health-care systems Article identifiers: Basic identifiers including name, authors, date, journal, article type and article design Methods: Types of research methods used in the article Geographical scale: Whether the study was conducted at a local, regional, national or international level Location: Relevant town or city, region, country and/or countries where the research was conducted Emission scope: Health-care operations (scope 1), energy (scope 2), supply chains (scope 3) Part of the health-care system: A particular aspect of the health-care system such as a primary health-care facility or a rural hospital Greenhouse gas mitigation intervention(s): Intervention details that lead to a decrease in greenhouse gas emissions Measurable effects of the greenhouse gas mitigation intervention(s): Quantified effects of the identified intervention(s) on mitigation, including a specification of greenhouse gas or carbon dioxide equivalent and whether it was measured or modelled Implementation process: A description of the implementation process, including enablers and barriers and how these were approached Implementation timeline: Timeline of the implementation process Economic analysis: Any provided economic information such as cost–effectiveness, cost–benefit or cost consequences Linkage with adaptation or resilience: Whether the intervention was directed at both mitigation and adaptation or if resilience was described. These interactions can be synergies, co-benefits, conflicts, trade-offs or co-harms19 Health effects: Measured effects on health outcomes or exposures Funding source: Source of funding for the authors Conflicts of interest: Further potential conflicts of interest, including relationships with relevant parties other than financial relationships Greenhouse gas mitigation interventions for health-care systems 162 Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Research were seen as a solution to enhance energy reliability and reduce energy costs over time.23 Suggested solutions included government funding, inter- national climate-related financing and renewable energy purpose obligations; with one article suggesting a 25-year implementation period.21–23 Wind and solar potential significantly influences their implementation, as areas with high potential (for example, those with strong insolation for solar energy), are more conducive to successful deployment than low-potential areas. Economic analysis Eight articles reported details on cost- ing, including their Net Present Costs (ranging from 3658 to 146 284 United States dollars, US$), payback periods (ranging from 3.38 to 9.9 years), and return metrics, which vary across dif- ferent systems and locations (Table 3). Health and health equity Five articles qualitatively estimated potential health effects, noting that reli- able hybrid energy systems can prevent power interruptions and address the lack of access to reliable electricity in rural areas. Without continuous access to electricity, the lack of essential medical equipment – such as incubators, ventila- tors and basic lighting, critical for safe childbirth and neonatal care – leads to a high rate of maternal and perinatal mortality ; spoilage of medication; and the inability to sterilize medical equipment used in operating rooms. In addition to the negative effects noted above, lack of coordination and com- munication (hindered by lack of reli- able access to electricity or broadband wireless networks) was also found to disproportionately affect the health care of women and children. Reliable electricity access can reduce these effects by increasing operating hours, attracting a larger health workforce, improving cold-chain for vaccines and medicines, and enhancing communication among health workers and between patients and health workers.20,23–25 Other important actions such as replacing diesel generators with hybrid systems can act to reduce harmful exposure to pollutants including un- burned hydrocarbons and particulate matter; potentially reducing risks for lung cancer, asthma and bronchitis;29 as well as contributing to a safer work environment particularly in laboratory settings.24 Adaptation Authors of one study examined the inter- section of mitigation and adaptation in the context of a solar photovoltaic energy system with and without grid-connection for a rural health-care facility in the Phil- ippines. They defined a climate-resilient energy system as providing “reliable, safe, and secure electricity during short‐term disasters and events and as longer‐term climate changes occur”, and found that this solar photovoltaic energy system could enable continued provision of care during both short- and longer-term climate change effects.23,47 Waste interventions Of the eight studies on waste that we iden- tified, one study covered plasma melting; used for melting medical waste. Plasma melting appears to have the highest over- all relative greenhouse gas emissions as compared to alternative waste interven- tions.37 Four studies covered stand-alone incineration and a mix of incineration with landfilling or autoclaving, which have the second highest emission.30–32,37 Relative emission reductions can be achieved by centralizing the autoclave, ensuring efficient transportation and having well-trained operators.31,36 One article also considered water usage, and found that combining autoclaving with incineration may conserve 38 967 m3 of water annually compared to incineration alone (Table 2).31 Systems integrating waste segrega- tion, composting and material recy- cling, all while optimizing transport, achieved the greatest emission reduc- tions, ranging from 47%–114%.30,32–34 Any further reductions in emissions were achieved through material recov- ery.32 For example, cardboard sharps containers were found to reduce black carbon emissions by 62% compared to plastic sharps containers in an inciner- ation-only system.35 Reported methodological limita- tions around waste management data include: (i) neglecting heat recovery;30,37 (ii) lack of accurate waste data;32 (iii) in- ability to measure electricity during op- erations and autoclaving;33 (iv) foreign emission factors;33 and (v) omission of transportation.34,37 Unintended negative consequences of waste management include ineffective segregation lead- ing to exposure to hazardous items,30 and generation of toxic dioxin during recycling.34 Fig. 1. Flowchart of the selection of studies on greenhouse gas mitigation interventions for health-care systems 25 570 records identified from: • 4026 from MEDLINE® • 10 875 from Embase® • 3474 from Global Health • 4368 from Web of Science™ • 1136 from Africa-Wide Information • 613 from LILACS • 124 from Global Index Medicus • 954 from GreenFile 19 292 records screened 6278 records removed before screening: • 6249 duplicate records removed • 29 records published before 1990 18 993 records excluded 16 reports not retrieved 261 reports excluded: • 132 did not report on emissions • 114 covered the wrong topic • 15 had the wrong study design 299 reports sought for retrieval 283 reports assessed for eligibility 22 studies included in review Research 163Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Greenhouse gas mitigation interventions for health-care systems Fig . 2 . Ge og ra ph ica l d ist rib ut io n of th e i nc lu de d st ud ie s o n gr ee nh ou se g as m iti ga tio n in te rv en tio ns fo r h ea lth -c ar e s ys te m s 0 87 5 17 50 3 50 0 km N no ta s: un a e sc al a d e 1 00 en 10 0 km s ( 10 0 km s eq ui va le n a 1 cm en es te m ap a) No . o f s tu di es 1 6 Greenhouse gas mitigation interventions for health-care systems 164 Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Research Ta bl e 1. D et ai le d su m m ar y o f i nc lu de d st ud ie s o n gr ee nh ou se g as m iti ga tio n in te rv en tio ns fo r h ea lth -c ar e s ys te m s St ud y St ud y d es ig n Ye ar of in te rv en tio n Co un tr y, W HO re gi on In co m e l ev el He al th sy st em le ve l St ud y s ite (s) Ah m ad za de ht al at ap eh & Ya u, 20 11 38 An al yt ic al a nd m od el lin g NR M al ay sia , W es te rn P ac ifi c Re gi on Up pe r-m id dl e- in co m e Ho sp ita l w ar d O ne o rth op ae di c w ar d Al i e t a l., 20 16 30 De sc rip tiv e: c ro ss - se ct io na l 20 14 –2 01 5 Pa ki st an , E as te rn M ed ite rra ne an Re gi on Lo w er -m id dl e- in co m e Ho sp ita l Te rti ar y ho sp ita l Ch ow dh ur y et a l., 20 21 20 De sc rip tiv e: c as e re po rt NR Ba ng la de sh , S ou th -E as t A sia Re gi on Lo w er -m id dl e- in co m e He al th -c ar e fa ci lit y O ne te m po ra ry ru ra l h ea lth -c ar e ce nt re on a n isl an d Ci pl ak , 2 01 53 1 De sc rip tiv e: c ro ss - se ct io na l NR Tü rk iy e, E ur op ea n Re gi on Up pe r-m id dl e- in co m e Re gi on w ith in c ou nt ry O ne re gi on Da tta e t a l., 20 16 39 An al yt ic al : e xp er im en ta l 20 15 In di a, So ut h- Ea st A sia R eg io n Lo w er -m id dl e- in co m e O ut pa tie nt su rg er y Pa ed ia tri c ey e ex am in at io ns a t o ne ho sp ita l Du ra iv el u & El um al ai , 2 02 12 1 De sc rip tiv e: c as e re po rt 20 19 In di a, So ut h- Ea st A sia R eg io n Lo w er -m id dl e- in co m e Ho sp ita l O ne u rb an h os pi ta l Isa e t a l., 20 16 22 An al yt ic al a nd m od el lin g NR M al ay sia , W es te rn P ac ifi c Re gi on Up pe r-m id dl e- in co m e Ho sp ita l O ne u ni ve rs ity h os pi ta l Kh an e t a l., 20 19 32 De sc rip tiv e: c as e se rie s 20 16 –2 01 7 Pa ki st an , E as te rn M ed ite rra ne an Re gi on Lo w er -m id dl e- in co m e Cl in ic 37 1 pr iv at e cl in ic s Kh or e t a l., 20 20 33 An al yt ic al : o bs er va tio na l: ca se -c on tro l 20 17 M al ay sia , W es te rn P ac ifi c Re gi on Up pe r-m id dl e- in co m e Ho sp ita l O ne h os pi ta l Le m en ce & Ta m ay ao , 2 02 12 3 An al yt ic al a nd m od el lin g NR Ph ilip pi ne s, W es te rn P ac ifi c Re gi on Lo w er -m id dl e- in co m e He al th -c ar e fa ci lit y O ne ru ra l h ea lth -c ar e fa ci lit y Li u et a l., 20 22 34 An al yt ic al a nd m od el lin g 20 50 Ch in a, W es te rn P ac ifi c Re gi on Up pe r-m id dl e- in co m e He al th -c ar e sy st em Ho sp ita ls, c om m un ity h ea lth se rv ice ce nt re s, to w ns hi p he al th c en tre s, an d vi lla ge c lin ic s Na ra ng e t a l., 20 17 24 De sc rip tiv e: c as e re po rt 20 15 –2 01 6 In di a, So ut h- Ea st A sia R eg io n Lo w er -m id dl e- in co m e Cl in ic al la bo ra to ry O ne la bo ra to ry O la to m iw a et a l., 20 18 25 De sc rip tiv e: c as e se rie s NR Ni ge ria , A fri ca n Re gi on Lo w er -m id dl e- in co m e Cl in ic Si x ru ra l c lin ic s i n six d iff er en t r eg io ns Pa ks oy e t a l., 20 00 26 De sc rip tiv e: c as e re po rt NR Tü rk iy e, E ur op ea n Re gi on Up pe r-m id dl e- in co m e Ho sp ita l O ne u ni ve rs ity h os pi ta l Pa nw ar e t a l., 20 13 27 An al yt ic al a nd m od el lin g 20 11 –2 01 2 In di a, So ut h- Ea st A sia R eg io n Lo w er -m id dl e- in co m e He al th -c ar e sy st em (s ub na tio na l) O ne c ity Pi na e t a l., 20 21 28 An al yt ic al a nd m od el lin g NR Br az il, Re gi on o f t he A m er ic as Up pe r-m id dl e- in co m e Ho sp ita l O ne u ni ve rs ity h os pi ta l Ra gh uw an sh i & A ry a, 20 20 29 De sc rip tiv e: c as e re po rt NR In di a, So ut h- Ea st A sia R eg io n Lo w er -m id dl e- in co m e He al th -c ar e fa ci lit y O ne re m ot e he al th -c ar e ce nt re Ra ila & A nd er so n, 2 01 73 5 An al yt ic al : e xp er im en ta l 20 14 Ha iti , R eg io n of th e Am er ic as Lo w er -m id dl e- in co m e He al th -c ar e sy st em (s ub na tio na l) Fiv e he al th -c ar e w as te in ci ne ra to rs Su n & Hu an g, 2 01 74 0 An al yt ic al a nd m od el lin g NR Ch in a, W es te rn P ac ifi c Re gi on Up pe r-m id dl e- in co m e O ut pa tie nt su rg er y Lo bb y of o ut pa tie nt d ep ar tm en t o f a ho sp ita l Th ie l e t a l., 20 17 41 De sc rip tiv e: c as e se rie s 20 14 In di a, So ut h- Ea st A sia R eg io n Lo w er -m id dl e- in co m e Su rg er y 2 te rti ar y ca re c en tre s Za ka ria e t a l., 20 05 36 De sc rip tiv e: c ro ss - se ct io na l NR Eg yp t, Ea st er n M ed ite rra ne an Re gi on Lo w er -m id dl e- in co m e He al th -c ar e sy st em (s ub na tio na l) Si x ho sp ita l w as te in ci ne ra to rs Zh ao e t a l., 20 21 37 An al yt ic al a nd m od el lin g NR Ch in a, W es te rn P ac ifi c Re gi on Up pe r-m id dl e- in co m e He al th -c ar e sy st em (s ub na tio na l) O ne c ity NR : n ot re po rte d; W HO : W or ld H ea lth O rg an iza tio n. No te : In co m e le ve l f ol lo w s t he cl as sifi ca tio n of th e W or ld B an k.4 4 Research 165Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Greenhouse gas mitigation interventions for health-care systems Implementation Appropriate waste management also acts to improve health and safety while reducing greenhouse gas emissions.32 Three articles recommended scaling up the proposed waste management systems within their respective cities and regions,30–32 one more broadly across low- and middle-income coun- tries,31 while another recommended a global ban on plastic sharps contain- ers.35 For example, composting of biodegradable waste in Pakistan was easy to implement because of low management and operation costs.32 In Türkiye, incineration on its own was not feasible due to high costs.31 Ultimately, widespread segregation and material and energy recovery was recommended but funding may be a barrier to implementation.32 Factors contributing to successful interventions include introduction of new technology (such as a well- performing scrubber control system), capacity-building and carbon tax poli- cies.32,34,36 Barriers to successful imple- mentation include unskilled operators, ineffective segregation and illegal removal of waste for recycling. Several policy interventions were suggested by the authors to deal with these potential barriers.30,34,36 Economic analysis In a study from China, authors esti- mated that appropriate plastic recycling in the health-care system would lead to a cumulative economic benefit of about US$ 450 million in 2050.34 In another article, a cost–benefit analysis indicates that electricity generation from waste can cover a large portion of the fuel expenses of transportation and incin- eration of medical waste.32 Health and health equity Reducing black carbon and sulfur emissions from incineration can re- duce health risks, such as respiratory infections, low birth weight, premature deaths and asthma, in localities where incineration is happening nearby.35,36 Although waste burning is a relatively small contributor to black carbon globally, it is a substantial contributor to health-related illnesses in locations with high black carbon exposure such as in China, India, Nigeria and Repub- lic of Korea.48 Critical appraisal and risk of bias Definitions of relevant methodologi- cal terms in the included studies were generally clear, but details on methods were missing in nine out of 22 (41%) articles. Fourteen studies (64%) report- ed on modelled outcomes, and eight (36%) reported on empirical outcomes. Some outcomes lacked transparency (missing data, time frames or units; six studies, 27%) and/or lack of con- founding (eight studies, 36%). Seven articles (32%) did not clearly state assumptions, and 14 (64%) did not clearly state limitations. We did not note a conflict of interest partly because 12 articles (55%) did not include a conflict-of-interest statement. Funding sources included health ministry funds, government funds, national founda- tions and institutes, university grants, corporations,23 research councils and national programmes (Table 4). As no protocols were published in advance, we could not compare and identify selective reporting for any of the articles. None of the articles self- reported potential meta-biases. Confidence in cumulative evidence We evaluated confidence in the avail- able evidence regarding the effect size of greenhouse gas emission reductions using the GRADE certainty assessment (Table 5), which is described in detail in the online repository.15 Across all 10 articles on energy, outcomes were assessed, as they spanned a variety of hybrid energy systems that included renewable energy resources. Regard- ing waste, we assessed four separate outcomes based on the different inter- ventions described in the articles. The four remaining articles were assessed as separate outcomes in the text. Discussion Here we provide an overview of peer- reviewed evidence on greenhouse gas mitigation interventions for health-care systems in low- and middle-income countries. The eligible studies show reductions in greenhouse gas emissions, cost savings as well as potential positive health effects. Because the overall health sectoral emissions contribute to about 5% of global greenhouse gas emission, successful mitigation efforts need to be urgently scaled up to affect overall emis- sions. For example, in 2015, Chinese health-care systems emitted an estimat- ed 302 megatonnes (Mt) of carbon di- oxide, while the Kenyan and Malaysian systems emitted an estimated 2 Mt and 6 Mt of carbon dioxide, respectively.2 In our identified studies, the maximum reductions were approximately 0.9 Mt of carbon dioxide equivalent annu- ally for a sustainable waste approach in China; and 0.02 Mt of carbon dioxide equivalent for a hybrid polygeneration energy system in a Brazilian hospital.28,34 However, due to the limited identified records and inconsistent methods, the overall quality of evidence is low and supports the conclusion that rigorous research, publication and dissemination is needed. Fully renewable energy with bat- tery storage, or hybrid energy systems including renewable and conventional sources provide a reliable and sustain- able source of electricity, especially in areas with intermittent or unreliable grid electricity supply; and require decision-makers interested in imple- menting renewable energy systems to consider local conditions, such as energy prices, solar and wind param- eters, and temperature to optimize performance and sustainability. A primary barrier to implementation is the high initial cost to purchase, install and maintain such systems or interventions. Irrespective of these barriers, we identified seven articles that reported positive returns, sug- gesting that the long-term benefits of implementing renewable energy systems outweigh the initial costs of implementation. Adequate funding is therefore crucial to support the initial setup of these mitigation interven- tions. Our results highlight actions such as waste segregation, compost- ing and material recycling as means to reduce greenhouse gas emissions, which is consistent with evidence from other sectors and high-income country settings.49,50 Waste-to-energy technologies such as incineration, autoclaving and microwave steriliza- tion could contribute more to green- house gas emission reductions than plasma melting or landfilling. We recommend that health-care facilities prioritize waste reduction, segregation and recycling, and address identified barriers through capacity-building and incentives before considering waste-to-energy technologies. How- Greenhouse gas mitigation interventions for health-care systems 166 Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Research Ta bl e 2. I nt er ve nt io ns an d ou tc om es in st ud ie s o n gr ee nh ou se g as m iti ga tio n in te rv en tio ns fo r h ea lth -c ar e s ys te m s Co un tr y, re fe re nc e Sc op e a nd in te rv en tio n ty pe Su m m ar y o f i nt er ve nt io n Ty pe of ou tc om e m ea su re m en t Re du ct io n CO 2(e qu iv al en t) kg / ye ar u nl es s o th er w ise st at ed (% ) Re du ct io n of ot he r g re en ho us e g as es pe r y ea r u nl es s o th er w ise st at ed Ba ng la de sh 20 El ec tri ci ty : E ne rg y A hy br id p ho to vo lta ic -c on ve rte r-w in d- ba tte ry -g en er at or e ne rg y ge ne ra tio n sy st em fo r a te m po ra ry h ea lth c en tre is c om pa re d to : Sy st em A : a h yb rid w in d- ge ne ra to r-c on ve rte r-b at te ry sy st em ; a nd Sy st em B : a h yb rid p ho to vo lta ic g en er at or -c on ve rte r-b at te ry sy st em M od el le d Co m pa re d to : Sy st em A : N R (2 7) Sy st em B : N R (2 5) Co m pa re d to sy st em A : CO : 2 0 4 96 k g PM : 1 24 k g Un bu rn ed h yd ro ca rb on : 8 95 k g SO 2: 6 5 69 k gb N O x: 19 25 4 kg In di a2 1 El ec tri ci ty : E ne rg y A 5- kW p on -g rid so la r p ho to vo lta ic ro of to p sy st em fo r o ne u rb an ho sp ita l i s c om pa re d to so le ly g rid -p ro vi de d el ec tri ci ty M od el le d 11 28 7 (N R) SO 2: 8. 86 k gb NO x: 18 .5 0 kg As h: 4 85 .7 92 k g M al ay sia 22 El ec tri ci ty : e ne rg y an d he at in g A gr id -c on ne ct ed p ho to vo lta ic -fu el c el l-b at te ry sy st em fo r e ne rg y an d he at in g of o ne u ni ve rs ity h os pi ta l b ui ld in g is co m pa re d to a st an da rd , s ta nd al on e di es el sy st em M od el le d 71 00 4 (7 4) CO : 2 39 k g Un bu rn ed h yd ro ca rb on : 2 6. 4 kg PM : 1 8 kg SO x: 83 k g NO x: 20 75 .5 k g Ph ilip pi ne s2 3 El ec tri ci ty : e ne rg y A so la r p ho to vo lta ic p an el e ne rg y sy st em w ith a nd w ith ou t g rid co nn ec tio n fo r a ru ra l h ea lth -c ar e fa ci lit y is co m pa re d to a g rid - on ly sy st em Em pi ric al W ith : 1 9 5 98 (5 9) W ith ou t: 62 77 6 (7 2) NR In di a2 4 El ec tri ci ty : e ne rg y A so la r p ho to vo lta ic p an el fo r a la bo ra to ry is c om pa re d to el ec tri ci ty fr om th e gr id M od el le d 13 86 0 (1 00 )a NR Ni ge ria 25 El ec tri ci ty : e ne rg y O pt im al h yb rid re ne w ab le sy st em c on fig ur at io ns fo r e le ct ric ity ge ne ra tio n (p ho to vo lta ic -w in d- di es el -b at te ry h yb rid sy st em co nfi gu ra tio n an d ph ot ov ol ta ic -d ie se l-b at te ry h yb rid sy st em co nfi gu ra tio n de pe nd in g on th e lo ca tio n) fo r s ix ru ra l c lin ic s f ro m six d iff er en t a re as a re c om pa re d to a d ie se l g en er at or sy st em M od el le d 20 11 3 (8 3) NR Tü rk iye 26 El ec tri ci ty : e ne rg y, he at in g an d co ol in g Us in g so la r e ne rg y in c om bi na tio n w ith a qu ife r t he rm al e ne rg y st or ag e fo r e le ct ric ity g en er at io n fo r h ea tin g an d co ol in g fo r o ne un iv er sit y ho sp ita l i s c om pa re d to u sin g oi l a nd th e el ec tri ci ty g rid M od el le d 2 1 00 00 0 SO x: 7 0 00 k g NO x: 8 0 00 t In di a2 7 El ec tri ci ty : e ne rg y A so la r p ho to vo lta ic tu nn el d ry er fo r s ur gi ca l c ot to n fo r o ne c ity is co m pa re d to a d ry er o n: li gh t d ie se l o il or li qu efi ed p et ro le um g as M od el le d Co m pa re d to : Di es el : 1 2 1 50 (1 00 ) Ga s: 6 7 20 (1 00 ) NR Br az il2 8 El ec tri ci ty : e ne rg y A hy br id p ol yg en er at io n sy st em fo r t he p ro vi sio n of e le ct ric ity to a ho sp ita l u nd er fo ur le ga l s ce na rio s i s c om pa re d to st an da rd u sa ge of th e el ec tri ci ty g rid . T he le ga l s ce na rio s a re : 39 .1 : P ur ch as e on ly : n o sa le o f e le ct ric ity a llo w ed ; 39 .2 : A nn ua l c on su m er : p ur ch as e an d sa le a re a llo w ed w ith th e co nd iti on o f p ur ch as in g m or e el ec tri ci ty th an sa le s a nn ua lly ; 39 .3 : U nr es tri ct ed sa le : p ur ch as e an d sa le a re a llo w ed w ith n o re st ra in ts ; a nd 39 .4 : E xc es s e le ct ric ity p ro du ct io n is in je ct ed in to th e di st rib ut io n ne tw or k, cr ea tin g en er gy c re di ts in k W h, b y m ea ns o f a fr ee lo an . M od el le d 39 .1 : 4 85 2 0 36 (6 3) 39 .2 : 6 84 4 2 07 (9 0) 39 .3 : 1 7 7 74 49 1 (2 33 ) 39 .4 : 1 7 7 74 49 1 (2 33 ) NR (c on tin ue s. . . ) Research 167Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Greenhouse gas mitigation interventions for health-care systems Co un tr y, re fe re nc e Sc op e a nd in te rv en tio n ty pe Su m m ar y o f i nt er ve nt io n Ty pe of ou tc om e m ea su re m en t Re du ct io n CO 2(e qu iv al en t) kg / ye ar u nl es s o th er w ise st at ed (% ) Re du ct io n of ot he r g re en ho us e g as es pe r y ea r u nl es s o th er w ise st at ed In di a2 9 El ec tri ci ty : e ne rg y A ph ot ov ol ta ic -d ie se l-b at te ry e ne rg y sy st em fo r e ne rg y ge ne ra tio n fo r a re m ot e he al th -c ar e ce nt re is c om pa re d to a d ie se l-b at te ry en er gy sy st em M od el le d 18 13 (4 6) CO : 4 .4 8 kg Un bu rn ed h yd ro ca rb on s: 0. 49 6 kg PM : 0 .3 37 k g SO 2: 3. 64 k gb NO : 4 0 kg Pa ki st an 30 Su pp ly c ha in : w as te An in te gr at ed sy st em o f h os pi ta l s ol id w as te tr ea tm en t a nd di sp os al c on sis tin g of c om po st in g, in ci ne ra tio n, a nd m at er ia l re cy cl in g is co m pa re d to th e st an da rd sc en ar io o f i nc in er at io n an d la nd fil l o r i nc in er at io n on ly Em pi ric al Co m pa re d to : St an da rd : 2 80 6 (6 2) In ci ne ra tio n on ly : 2 61 0 (4 7) NR Tü rk iye 31 Su pp ly c ha in : w as te A re gi on al h ea lth -c ar e w as te m an ag em en t s ce na rio o f a ce nt ra liz ed a ut oc la ve c ou pl ed w ith a n in ci ne ra to r i s c om pa re d to : Sc en ar io 1 : a n in ci ne ra to r; Sc en ar io 2 : d ec en tra liz ed a ut oc la vi ng co up le d w ith a n in ci ne ra to r M od el le d Co m pa re d to : Sc en ar io 1: 1 54 4 0 00 Sc en ar io 2 : 1 76 7 0 00 NR Pa ki st an 32 Su pp ly c ha in : w as te Se gr eg at io n in to m ed ic al w as te (w hi ch is in ci ne ra te d w ith tra ns po rta tio n by m ot or bi ke s a nd th en se nt to la nd fil l), a nd ge ne ra l w as te (f ro m w hi ch m at er ia l i s r ec ov er ed o r c om po st ed a nd th en se nt to la nd fil l), is c om pa re d to : Sc en ar io 1 : s eg re ga tio n w ith la nd fil lin g of g en er al w as te a nd in ci ne ra tio n of m ed ic al w as te , t he n la nd fil lin g, a nd Sc en ar io 2 : in ci ne ra tio n an d th en la nd fil lin g of a ll w as te Em pi ric al Co m pa re d to : Sc en ar io 1 : 5 38 p er to nn e of w as te (1 14 ) Sc en ar io 2 : 1 11 0 pe r t on ne o f w as te (1 06 ) NR M al ay sia 33 Su pp ly c ha in : w as te Se gr eg at io n an d re cy cl in g of w as te o f p ha co em ul sifi ca tio n su rg er y is co m pa re d to n o se gr eg at io n an d re cy cl in g in o ne h os pi ta l Em pi ric al 0. 13 9 pe r c as e NR Ch in a3 4 Su pp ly c ha in : w as te Pl as tic re cy cl in g in th e he al th -c ar e sy st em is c om pa re d to n o re cy cl in g M od el le d 86 8 7 00 00 0 (5 7) NR Ha iti 35 Su pp ly c ha in : w as te M ai ns tre am in g th e us e of c ar db oa rd sh ar ps h ea lth -c ar e w as te co nt ai ne rs in st ea d of p la st ic c on ta in er s a t fi ve h ea lth -c ar e w as te in ci ne ra to rs Em pi ric al NR Bl ac k ca rb on : 6 1. 68 % Eg yp t36 Su pp ly c ha in : w as te Co m pa rin g a ne w er in ci ne ra to r i nc lu di ng a h ig h- pe rfo rm an ce sc ru bb er c on tro l s ys te m a nd g oo d pr ac tic e pr oc es se s b y an ex pe rie nc ed o pe ra to r, w ith a n ol de r i nc in er at or w ith ou t s pe ci fie d pr oc es se s Em pi ric al NR CO : 3 35 8 m g/ m 3 ( 86 .8 ) Ch in a3 7 Su pp ly c ha in : w as te M ed ic al w as te m an ag em en t i n a ci ty th ro ug h m ic ro w av e st er iliz at io n w ith la nd fil l m ed ic al w as te d isp os al te ch no lo gy is co m pa re d to : r ot ar y ki ln in ci ne ra tio n; p yr ol ys is in ci ne ra tio n; p la sm a m el tin g an d st ea m st er iliz at io n w ith la nd fil l M od el le d Co m pa re d to : Pe r d isp os al ro ta ry k iln : 2 85 (6 8) Py ro ly sis : 5 2 (2 8) Pl as m a m el tin g: 5 51 (8 0) St ea m st er iliz at io n: 3 0 (1 8) NR M al ay sia 38 El ec tri ci ty : h ea tin g an d co ol in g An e ig ht -ro w p ip e he at e xc ha ng er sy st em a dd ed to th e ai r co nd iti on in g sy st em in o ne o rth op ae di c w ar d in a u ni ve rs ity ho sp ita l i s c om pa re d to a st an da rd a ir co nd iti on in g sy st em M od el le d 31 4 (1 47 )b NR (. . . co nt in ue d) (c on tin ue s. . . ) Greenhouse gas mitigation interventions for health-care systems 168 Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Research ever, identifying potential unintended negative consequences for the local community from waste produced by health-care facilities is essential, in- cluding pollution from incineration, when designing waste-management policies. Context-specific strategies to mitigate some of these effects need to be developed that are also sensitive to local socioeconomic and environ- mental conditions. Limited informa- tion on costs and potential benefits of waste management interventions in this systematic review underscores the need for further economic analysis. There is evidence to suggest that building design optimization and im- proved surgical processes can lead to reductions in greenhouse gas emissions; however, there is a dearth of data on the implementation, costing and health impacts of these interventions.38–41 Al- though we have reviewed several prom- ising interventions to reduce greenhouse gas emissions in health-care settings, there are gaps in our current knowledge of the implementation and sustainability of mitigation interventions and their potential scalability. These gaps restrict our understanding of the effects on overall sectoral emission reductions. Detailed information is lacking on the workforce required, the amount of implementation-related greenhouse gas emissions, and the time and resources needed for installation and deployment. Moreover, there is little information on other important issues such as long- term maintenance and upkeep. This study has some limitations. First, the findings may not encompass all pertinent factors leading to success- ful implementation because of a lack of descriptive details. Second, the absence of consistent reporting methods in the literature restricts the comparability and generalizability of the results and im- pedes further in-depth analysis. Third, the GRADE approach is designed for single interventions, which creates chal- lenges in the interpretation of systemic change. To overcome these limitations, further research is necessary to obtain more comprehensive evidence on the effectiveness, scalability and durability of mitigation interventions in health- care systems in low- and middle-income countries using standard approaches; for example by adapting guidelines for evaluation of complex interventions to the planetary health agenda.51,52 Co un tr y, re fe re nc e Sc op e a nd in te rv en tio n ty pe Su m m ar y o f i nt er ve nt io n Ty pe of ou tc om e m ea su re m en t Re du ct io n CO 2(e qu iv al en t) kg / ye ar u nl es s o th er w ise st at ed (% ) Re du ct io n of ot he r g re en ho us e g as es pe r y ea r u nl es s o th er w ise st at ed In di a3 9 He al th -c ar e op er at io ns : an ae st he tic g as es In du ct io n do se o nl y se vo flu ra ne d ur in g pa ed ia tri c ey e ex am in at io n fo r c hi ld re n ag ed 1 –5 y ea rs a t o ne h os pi ta l i s c om pa re d to st an da rd lo w -fl ow se vo flu ra ne Em pi ric al 77 00 (2 2) p er d ay o f 1 0– 12 pr oc ed ur es CO 2 e qu iv al en t i nc lu de s a re du ct io n of N 2O o f 3 .7 5 L/ ca se Ch in a4 0 El ec tri ci ty ; b ui ld in g de sig n Th e en er gy c on su m pt io n of a n ou tp at ie nt h os pi ta l l ob by b ui ld in g de sig n of a lo bb y of 1 6 m 2 w ith tw o ex te rio r w al ls, so ut h- or ie nt ed at th e sa m e he ig ht a s t he re st o f t he h os pi ta l i s c om pa re d to lo bb y de sig ns th at h av e a di ffe re nt n um be r o f e xt er io r w al ls, a d iff er en t or ie nt at io n, a nd a d iff er en t h ei gh t. Th en , d iff er en t w in do w –w al l ra tio s a nd sk yl ig ht ra tio s a re c om pa re d M od el le d 18 6– 10 11 a NR In di a4 1 He al th -c ar e op er at io ns , e le ct ric ity an d su pp ly c ha in : op er at io ns a nd lo gi st ic s Us ag e of m ul tiu se v ia l f or p ha rm ac eu tic al s, a sh or t s ur gi ca l du ra tio n, a nd a q ui ck tu rn ar ou nd ti m e du rin g ca ta ra ct su rg er y is co m pa re d to th e st an da rd p ra ct ice in a B rit ish h os pi ta l Em pi ric al 12 4 (9 5) p er c as e NR CO : c ar bo n m on ox id e; C O 2 : c ar bo n di ox id e; kW p: ki lo w at t p ea k; N 2 O: n itr ou s o xid e; N Ox : n itr og en o xid es ; N R: n ot re po rte d; P M : p ar tic ul at e m at te r; SO 2: su lfu r d io xid e; S Ox : s ul fu r o xid es . a Em iss io ns ca lcu la te d us in g na tio na l e m iss io n fa ct or s.4 5, 46 b SO 2 i s a co ol in g ae ro so l, s o re du ce d SO 2 e m iss io ns p ar tly o ffs et th e re du ct io n of th e he at in g eff ec t f ro m m iti ga tio n of g re en ho us e ga s e m iss io ns . (. . . co nt in ue d) Research 169Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Greenhouse gas mitigation interventions for health-care systems We found that the types of inter- ventions reported in the literature are limited to a few areas that contribute to emissions, namely energy, waste, heating and cooling, operations and lo- gistics, building design and anaesthetic gases. We also noted a lack of reported interventions in other subject areas including equipment efficiency; inhal- ers; food; manufacturing and efficient use of pharmaceuticals and chemicals; production, reduction and circularity of medical supplies and devices; partner- ships, purchasing and finance; informa- tion and communication technologies; telemedicine; community-based care; and supply-chain management.8 Fur- ther, interventions focusing on systemic efficiencies of delivery of high-quality care were not identified and improving the efficiency of health-care provision could provide another opportunity to reduce emissions (Box 3). There is a lack of data on how to consider context-specific adaptation and mitigation measures, particularly in low- and middle-income countries. Future research and interventions should consider a wider range of con- texts, including low-income countries, all scopes of emissions and adaptation. While efforts are increasing to mitigate greenhouse gas emissions from health- care systems, such as through WHO's Alliance for Transformative Action on Climate Change and Health,53 it is essential to robustly monitor, evalu- ate, record and report outcomes in a standardized manner. An example of a tool that could support such efforts is the recently launched HealthcareLCA database, which contains assessments focused on the environmental impact of health care.54 In addition, reviewing grey literature such as reports from nongovernmental organizations, local organizations and community-based initiatives could provide valuable insights into the implementation and sustainability of interventions in low- Box 5. Other greenhouse gas mitigation interventions in health-care systems Heat exchanger system, Malaysia A hospital ward in Malaysia incorporated an eight-row heat pipe heat exchanger into its air conditioning system, yielding savings equivalent to approximately 314 kg of carbon dioxide each year. This system also provides an economic benefit of about US$ 42 000 annually with a payback period of 1.6 years, and offers the added advantage of preventing Legionella growth in the ducting system.38 Sevoflurane use, India Using only the induction dose of sevoflurane for brief paediatric eye examinations in children aged 1–5 years reduced emissions in comparison to the traditional continuous low flow. Despite the high global warming potential of sevoflurane, this reduction in usage amounts to a modest climate benefit and cost savings of US$ 10 per day across 8–12 patients, enhancing health equity and affordability of this vital anaesthetic for children in low-resource settings.39 Building design, China A hospital's new outpatient lobby design in a colder region of China, featuring two south-facing exterior walls over a 16 m2 area, is expected to achieve a significant reduction in carbon dioxide emissions, between 186 and 1011 kg annually, due to the decreased need for heating.40 Multiuse pharmaceuticals and reusing surgical supplies, India Cataract surgery at the Aravind Eye Care Centre in India, when compared with similar procedures in the United Kingdom of Great Britain and Northern Ireland, showed that implementing multiuse pharmaceuticals and reusing surgical supplies led to a substantial 95% relative reduction in emissions. The centre also optimized surgical duration and turnaround times, running two adjacent operating rooms simultaneously, which contributed to better patient outcomes and lower complication rates. Nonetheless, the assessment acknowledged methodological limitations, including variance in greenhouse gas measurement techniques and a lack of life cycle inventories specific to India. The researchers advocated for the expansion of such interventions, suggesting new vision centres and the integration of telemedicine, supported by rigorous training and strict sterilization protocols. They highlighted that policy changes, particularly those allowing multiuse pharmaceuticals in more countries, are essential to mitigate the environmental impact of health-care practices.41 US$: United States dollars. Table 3. Studies reporting economic outcomes for greenhouse gas mitigation interventions for health-care systems Country Intervention Initial capital, US$ Net present cost, US$ Payback period, year Return on investment, % Initial rate of return, % Bangladesh20 Photovoltaic Converter-Wind- Battery-Generator energy generation system NR 69 377 300 7 NR NR India24 Solar panel 12 000 NR NR NR NR India27 Solar photovoltaic tunnel dryer for surgical cotton NR 10 660 3.38 86 to 150 NR India29 Photovoltaic-diesel-battery energy system NR 13 523 9.9 NR NR India21 5-kWp on-grid solar photovoltaic rooftop system 3 658 NR 7.1 NR NR Malaysia22 Grid-connected photovoltaic fuel cell-battery system NR 98 318 NR NR NR Nigeria25 Optimal hybrid renewable system configurations for electricity generation NR 71 210 to 108 920 NR NR NR Philippines23 A solar photovoltaic panel energy system with or without grid connection NR With: 87 139 Without: 146 284 With: 9.7 Without: 4.5 With: 6.10; Without: 15.90 With: 9.0 Without: 20.8 kWp: kilowatt peak; US$: United States dollars. Greenhouse gas mitigation interventions for health-care systems 170 Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Research Ta bl e 4. C rit ica l a pp ra isa l o f s tu di es in clu de d in th e s ys te m at ic re vi ew on g re en ho us e g as m iti ga tio n in te rv en tio ns fo r h ea lth -c ar e s ys te m s Co un tr y, re fe re nc e De fin iti on s M et ho ds Re su lts Co nf ou nd in g Di sc us sio n Cl ea r d efi ni tio n of th e o bj ec tiv e or h yp ot he sis ? Cl ea r d efi ni tio n of in te rv en tio n or ex po su re ? Cl ea r d efi ni tio n of ou tc om e? Is/ ar e t he co nt ro l(s ) ap pr op ria te ? M et ho ds ap pl ie d co ns ist en tly ? Da ta re po rt ed tr an sp ar en tly ? Ty pe of ou tc om e m ea su re m en t us ed ? Ad dr es se d in d es ig n or an al ys is? As su m pt io ns cle ar ly st at ed ? Lim ita tio ns cle ar ly st at ed ? En er gy Ba ng la de sh 20 Ye s Ye s Ye s Ye s Ye s Ye s M od el le d Ye s Ye s No In di a2 1 Ye s Ye s Ye s Ye s Ye s Ye s M od el le d Ye s Ye s No M al ay sia 22 Ye s Ye s Ye s Ye s Ye s No M od el le d Ye s Ye s No Ph ilip pi ne s2 3 Ye s Ye s Ye s Ye s Ye s Ye s M od el le d Ye s Ye s Ye s In di a2 4 No Ye s Ye s Ye s No No Em pi ric al No No No Ni ge ria 25 Ye s Ye s Ye s Ye s Ye s Ye s M od el le d Ye s Ye s No Tu rk ey 26 Ye s Ye s Ye s Ye s NA No M od el le d Ye s No No In di a2 7 Ye s Ye s Ye s No NA Ye s M od el le d No Ye s No Br az il2 8 Ye s Ye s Ye s Ye s Ye s Ye s M od el le d Ye s Ye s No In di a2 9 Ye s Ye s Ye s Ye s Ye s Ye s M od el le d Ye s Ye s No W as te Pa ki st an 30 Ye s Ye s Ye s Ye s Ye s No Em pi ric al Ye s Ye s Ye s Tü rk iye 31 Ye s Ye s Ye s Ye s Ye s Ye s M od el le d Ye s Ye s No Pa ki st an 32 Ye s Ye s Ye s Ye s Ye s Ye s Em pi ric al No No Ye s M al ay sia 33 Ye s Ye s Ye s Ye s NA Ye s Em pi ric al No No Ye s Ch in a3 4 Ye s Ye s No Ye s NA Ye s M od el le d Ye s No Ye s Ha iti 35 Ye s Ye s Ye s Ye s Ye s Ye s Em pi ric al No Ye s No Eg yp t36 No No Ye s Ye s Ye s Ye s Em pi ric al No Ye s No Ch in a3 7 Ye s Ye s Ye s Ye s Ye s No M od el le d Ye s Ye s Ye s O th er s M al ay sia 38 Ye s Ye s Ye s No NA Ye s M od el le d No No No In di a3 9 Ye s Ye s Ye s Ye s Ye s Ye s Em pi ric al Ye s No Ye s Ch in a4 0 Ye s Ye s Ye s Ye s Ye s No M od el le d Ye s Ye s No In di a4 1 Ye s Ye s Ye s No No Ye s Em pi ric al No Ye s Ye s NA : n ot a pp lic ab le . Research 171Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Greenhouse gas mitigation interventions for health-care systems and middle-income countries. Add- ing grey literature can complement findings from academic research and fill gaps in knowledge, particularly in resource-constrained settings where formal research may be limited. Such evidence will, however, require critical assessment because of the potential for methodological weaknesses and conflicts of interest leading to biased findings. In conclusion, this review illustrates a wide range of interventions to mitigate greenhouse gas emissions in health-care systems in low and middle-income countries. We also highlight important gaps in the research-based knowledge. Further research, monitoring and evalu- ation are necessary to establish a robust evidence base and inform future policy decisions and interventions towards suc- cessful greenhouse gas mitigation and adaptation of health-care systems in the context of climate change.  Acknowledgements We thank Jane Falconer, Russel Burke, Kathleen Perris, Javier Shafick Asfura, Hugh Sharma Waddington, Neil Spicer, Rob Hughes, Roberto Picetti, the Path- finder Research Team, Fawzia Rasheed, Sandra Mounier-Jack and Susannah Mayhew. Table 5. Certainty of evidence for interventions to mitigate greenhouse gases for health-care systems, low- and middle-income countries Outcome Impact No. of studies Certainty of evidencea Greenhouse gas mitigation through hybrid energy systems A variety of hybrid energy systems, including renewable energy sources adjusted to contexts, reported reductions in carbon dioxide emissions ranging from 25% to a theoretical 233% 10 observational studies Low Greenhouse gas mitigation of health-care system waste through waste management systems with composting or recycling Relative emission reductions are reported ranging between 46%–114% in systems that include waste segregation, composting, and material recycling while considering efficient low-emission transportation options Four observational studies Low Greenhouse gas mitigation of health-care system waste through incineration and autoclave process efficiency Relative emission reductions in waste management systems are reported to take place through centralizing the autoclave (reduces electricity needed), considering efficient transportation, and ensuring incinerators are up-to-date with a clear process and well-trained operator Two observational studies Very lowb Greenhouse gas mitigation of health-care system waste through replacing plastic sharps containers by cardboard sharps containers Using cardboard sharps containers instead of plastic sharps containers led to a reported 62% reduction in black carbon emissions One observational study Very lowb Greenhouse gas mitigation of health- care system waste through microwave sterilization and landfilling Urban medical waste management through microwave sterilization with landfill medical waste disposal technology reduces relative emissions as compared to rotary kiln incineration (68%), pyrolysis incineration (28%), plasma melting (80%) and steam sterilization with landfill (18%) One observational study Low Greenhouse gas mitigation of health-care facility heating and cooling through heat exchangers An eight-row heat pipe heat exchanger system added to one hospital ward was assessed to reduce carbon dioxide emissions compared to the regular air conditioning system by 147%, because of heat generation One observational study Low Greenhouse gas mitigation of anaesthetic gases through induction dose only sevoflurane Induction dose only sevoflurane during paediatric eye examination for children aged 1–5 years at one hospital reduces 22% of emissions compared to standard low-flow sevoflurane One RCT High Greenhouse gas mitigation of a hospital building through lobby design In this cold-climate region, a lobby with two exterior walls, south-oriented at the same height as the rest of the hospital, emits the least with a relative reduction of 0.014– 0.074 kg CO2/m 2 depending on the comparison design One observational study Very lowc Greenhouse gas mitigation of operations and logistics of cataract surgery Multiuse pharmaceuticals, reusing surgical supplies, a short surgical duration and quick turnaround time resulted in a relative reduction of emissions of 95% as compared to the same surgery in the United Kingdom One observational study Very low Climate adaptation from mitigation interventions A solar photovoltaic panel energy system with and without grid-connection for a rural health-care facility in the Philippines may contribute to the resilience of a health-care facility to short-term disasters and events and as longer- term climate changes occur One observational study Very lowd CO2: carbon dioxide; RCT: randomized controlled trial. a We used the Grading of Recommendations Assessment, Development, and Evaluation approach. b Results (partially) based on visual observation of pollution. c Outcomes in electricity generated in carbon dioxide equivalent using national emission factors. d Adaptation was a consideration in the article and not measured. Greenhouse gas mitigation interventions for health-care systems 172 Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Research Funding: This work was supported by the Wellcome Trust (grant number 221284/Z/20/Z) with support from the Oak Foundation (grant number OFIL- 20-093) as part of the Pathfinder Initia- tive. IMB declares having received three partial grants for her studies: a Prince Bernhard Culture Fund grant number 40037327 was awarded on 15 September 2021; Stichting VSBFonds grant number VSB.21/00168 was awarded on 17 May 2021; Hendrik Mullerfonds without grant number was awarded on 9 December 2021. Competing interests: None declared. © 2024 The authors; licensee World Health Organization. This is an open access article distributed under the terms of the Creative Commons Attribution IGO License (http://creativecommons.org/licenses/by/3.0/igo/legalcode), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL. 摘 要 卫生保健系统实施温室气体减排干预措施的有效性 ：系统综述 目的 确定可以减少低收入和中等收入国家卫生保健系 统的温室气体排放的循证干预措施，并探索这些干预 措施在支持减排的同时在帮助适应气候变化方面的潜 在协同作用。 方法 我们系统地检索了 11 个电子数据库，以查找 1990 年至 2023 年 3 月之间发表的相关文章。我们评 估了每篇文章的偏倚风险，并对卫生保健业务、能源 和供应链干预措施的证据质量进行了分级。 结果 在筛选了 25,570 份不重复的记录后，我们纳入了 2000 年至 2022 年之间发表的 22 项研究，这些研究来 自世界卫生组织六个区域的 11 个不同国家。已确定 的文章报告了涉及六种不同排放源的干预措施，即能 源、废物、供暖和制冷、运营和物流、建筑设计和麻 醉气体 ；所有这些报告都表明干预措施有可能大幅减 少温室气体的排放、节约成本并对健康产生积极的影 响。由于温室气体排放测量和报告之间存在巨大差异， 证据的总体质量较低。 结论 在低收入和中等收入国家，减少卫生保健系统的 温室气体排放是可能的，但不同排放源的证据质量之 间存在差距（例如供应链），并缺乏对适应目标间相 互影响的考虑。随着温室气体减排工作的不断加强， 需要对这些工作进行严格的监测、评估和报告。这些 举措将有助于构建强有力的证据基础，从而为不同背 景下的政策制定者提供信息。 صخلم ةيجهنم ةعجارم :ةيحصلا ةياعرلا ةمظنأ في يرارلحا سابتحلاا تازاغ نم فيفختلل لخدتلا ةيلاعف نم للقت يتلاو ،ةلدلأا لىع ةمئاقلا تلاخدتلا ديدتح ضرغلا في ةيحصلا ةياعرلا ةمظنأ في يرارلحا سابتحلاا تازاغ تاثاعبنا لبس فاشكتساو ،طسوتلما لخدلاو ضفخنلما لخدلا تاذ لودلا فيكتلا لىع دعاست يتلاو ،تلاخدتلا هذه نم ةلمتحلما جامدنلاا .تاثاعبنلاا فيفتخ عم خانلما يرغت عم ةينوتركلإ تانايب ةدعاق 11 في يجهنم لكشب ثحبلاب انمق ةقيرطلا .2023 راذآ/سرام ىتحو 1990 ماع نم ةروشنلما تلااقملل ةلدلأا ةدوج فينصتو ،ةلاقم لك في زيحتلا رطخ مييقتب انمقو لسلاسو ،ةقاطلاو ،ةيحصلا ةياعرلا تايلمع في تلاخدتلا برع .ديروتلا ةسارد 22 ينمضتب انمق ،اًديرف ًلاجس 25570 صحف دعب جئاتنلا تس برع ةفلتمخ ةلود 11 نم ،2022و 2000 يماع ينب ةروشنم ةراشلإا تتم يتلا تلااقلما نإ .ةيلماعلا ةحصلا ةمظنلم ةعبات قطانم ،تاثاعبنلال ةفلتمخ رداصم ةتس برع دتتم ،تلاخدتلا تلوانت انهأ لىإ تامدلخاو تايلمعلاو ،ديبرتلاو ةئفدتلاو ،تايافنلاو ،ةقاطلا يهو ترهظأ دقو ؛ريدختلا تازاغو ،نيابلما ميمصتو ،ةيتسجوللا تازاغ تاثاعبنا في ةيربك تاضيفتخ قيقتح ةيناكمإ اهعيجم لىع ةيبايجإ تايرثأت قيقتحو ،فيلاكتلا يرفوتو ،يرارلحا سابتحلاا في يربكلا نيابتلا ببسب ةضفخنم ةلدلأل ةيلاجملإا ةدولجا .ةحصلا .اهنع غلابلإاو ،يرارلحا سابتحلاا تازاغ تاثاعبنا سايق سابتحلاا تازاغ تاثاعبنا نم دحلل صرف كانه جاتنتسلاا لخدلا تاذ لودـلا في ةيحصلا ةياعرلا ةمظنأ نم يرارـلحا في ةلدلأا في تارغث ديدتح مت نكلو ،طسوتلما لخدلاو ضفخنلما ةاعارم مدع نع ًلاضف ،ديروتلا ةلسلس لثم ؛تاثاعبنلاا رداصم لىإ ةيمارلا دوهلجا فيثكت عمو .فيكتلا فادهأ عم تلاعافتلا دصر لىإ ةجاح كانه ،يرارلحا سابتحلاا تازاغ نم فيفختلا لثم مهستس .طشن لكشب اهنع غلابلإاو ،اهمييقتو ،دوهلجا هذه يعضاو ةيعوت اهنكمي ،ةلدلأل ةيوق ةدعاق ءاشنإ في تاءارجلإا هذه .ةفلتخلما عاضولأا في تاسايسلا Research 173Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Greenhouse gas mitigation interventions for health-care systems Résumé Efficacité des interventions visant à réduire les émissions de gaz à effet de serre dans les systèmes de soins de santé: revue systématique Objectif Identifier les interventions fondées sur des données factuelles qui visent à réduire les gaz à effet de serre émanant des systèmes de soins de santé dans les pays à revenu faible et intermédiaire, mais aussi explorer d'éventuelles synergies liées à ces interventions et susceptibles de contribuer à une meilleure adaptation au changement climatique tout en réduisant les émissions. Méthodes Nous avons procédé à une analyse systématique de 11 bases de données électroniques, à la recherche d'articles publiés entre 1990 et mars 2023. Pour chaque article, nous avons déterminé le risque de biais et évalué la qualité des données relatives aux interventions dans les unités de soins de santé, l'énergie et les chaînes d'approvisionnement. Résultats Après avoir examiné 25 570 documents uniques, nous avons conservé 22 études publiées entre 2000 et 2022, issues de 11 pays appartenant à six régions de l'Organisation mondiale de la Santé. Les articles retenus mentionnaient des interventions couvrant six sources d'émissions différentes, à savoir l'énergie, les déchets, le chauffage et la climatisation, les opérations et services logistiques, la conception des bâtiments, ainsi que les gaz anesthésiques; toutes ont révélé un potentiel en matière de réduction des émissions de gaz à effet de serre, de réalisation d'économies et d'impact positif sur la santé. Globalement, les données sont de piètre qualité en raison des variations des mesures et rapports concernant les émissions de gaz à effet de serre. Conclusion Il existe plusieurs moyens de réduire les émissions de gaz à effet de serre provenant des systèmes de soins de santé dans les pays à revenu faible et intermédiaire. Cependant, les preuves sur les sources d'émissions manquent, notamment au niveau de la chaîne d'approvisionnement, et les interactions à des fins d'adaptation ne sont que rarement prises en compte. Alors que les efforts visant à réduire ces émissions se multiplient, il est impératif de les surveiller, de les évaluer et d'établir des rapports rigoureux. De telles actions contribueront à mieux étayer les données afin d'orienter les responsables politiques en fonction du contexte. Резюме Эффективность мер по снижению выбросов парниковых газов для систем здравоохранения: систематический обзор Цель Выявить научно обоснованные меры, направленные на сокращение выбросов парниковых газов в системах здравоохранения в странах с низким и средним уровнем дохода, и изучить возможный синергетический эффект от этих мер, способствующих адаптации к изменению климата и одновременно снижающих уровень выбросов. Методы Авторы изучили 11 электронных баз данных в поисках статей, опубликованных в период с 1990 года по март 2023 года. Оценивался риск возникновения системной ошибки в каждой статье и качество доказательств по различным видам вмешательств в секторах работ в области здравоохранения, энергопотребления и цепочки поставок. Результаты После проверки 25 570 уникальных записей в обзор были включены 22 исследования, опубликованные в период с 2000 по 2022 год в 11 разных странах, представляющих шесть регионов Всемирной организации здравоохранения. В найденных статьях сообщалось о мерах, охватывающих шесть различных источников выбросов, а именно: энергопотребление, отходы, обогрев и охлаждение, эксплуатацию и логистику, проектирование зданий и анестетические газы. Каждая из них продемонстрировала потенциал для значительного сокращения выбросов парниковых газов, экономии затрат и положительного воздействия на здоровье. Общее качество доказательств оценивается как низкое из-за большого разброса в измерении и отчетности по выбросам парниковых газов. Вывод Существуют возможности для сокращения выбросов парниковых газов от систем здравоохранения в странах с низким и средним уровнем дохода, однако были выявлены пробелы в фактических данных по всем источникам выбросов, таким как цепочка поставок, а также недостаточное рассмотрение взаимодействия с целями адаптации. Поскольку предпринимаются все более активные усилия по сокращению выбросов парниковых газов, необходимы тщательный мониторинг и оценка этих усилий, а также отчетность о таких усилиях. Такие меры будут способствовать созданию прочной доказательной базы, которая будет служить источником информации для ответственных лиц в различных контекстах. Resumen Eficacia de la intervención para mitigar los gases de efecto invernadero en los sistemas sanitarios: una revisión sistemática Objetivo Identificar intervenciones basadas en evidencias que reduzcan las emisiones de gases de efecto invernadero en los sistemas sanitarios de los países de ingresos bajos y medios y explorar las posibles sinergias de estas intervenciones que ayuden a adaptarse al cambio climático mientras se mitigan las emisiones. Métodos Se realizaron búsquedas sistemáticas en 11 bases de datos electrónicas de artículos publicados entre 1990 y marzo de 2023. Se evaluó el riesgo de sesgo en cada artículo y se clasificó la calidad de las pruebas en las intervenciones relacionadas con las operaciones sanitarias, la energía y las cadenas de suministro. Resultados Tras examinar 25 570 registros únicos, se incluyeron 22 estudios publicados entre 2000 y 2022 de 11 países de seis regiones de la Organización Mundial de la Salud. Los artículos identificados informaron sobre intervenciones que abarcaban seis fuentes diferentes de emisiones: energía, residuos, calefacción y refrigeración, operaciones y logística, diseño de edificios y gases anestésicos; todos ellos demostraron potencial para reducciones significativas de las emisiones de gases de efecto invernadero, ahorro de costes e impactos positivos en la salud. La calidad general de las evidencias es baja debido a la gran variación en la medición y la notificación de las emisiones de gases de efecto invernadero. Greenhouse gas mitigation interventions for health-care systems 174 Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Research Conclusión Existen oportunidades para reducir las emisiones de gases de efecto invernadero de los sistemas de atención sanitaria en los países de ingresos bajos y medios, pero se han detectado deficiencias en las evidencias de las diferentes fuentes de emisiones, como la cadena de suministro, así como una falta de consideración de las interacciones con los objetivos de adaptación. A medida que se intensifican los esfuerzos para mitigar los gases de efecto invernadero, es necesario realizar un seguimiento, una evaluación y una notificación rigurosos de estos esfuerzos. Estas medidas contribuirán a crear una base de evidencias sólida que pueda informar a los responsables de formular las políticas en todos los contextos. References 1. WHO calls for urgent action to protect health from climate change – Sign the call [internet]. Geneva: World Health Organization; 2015. Available from: https:// www .who .int/ news/ item/ 06 -10 -2015 -who -calls -for -urgent -action -to -protect -health -from -climate -change -sign -the -call [cited 2023 Jun 15]. 2. Lenzen M, Malik A, Li M, Fry J, Weisz H, Pichler P-P, et al. The environmental footprint of health care: a global assessment. Lancet Planet Health. 2020 Jul;4(7):e271–9. doi: http:// dx .doi .org/ 10 .1016/ S2542 -5196(20)30121 -2 PMID: 32681898 3. Romanello M, Di Napoli C, Drummond P, Green C, Kennard H, Lampard P, et al. The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels. Lancet. 2022 Nov 5;400(10363):1619–54. doi: http:// dx .doi .org/ 10 .1016/ S0140 -6736(22)01540 -9 PMID: 36306815 4. Environmentally sustainable health systems: a strategic document. Copenhagen: World Health Organization Regional Office for Europe; 2017. Available from: https:// www .who .int/ publications/ i/ item/ WHO -EURO -2017 -2241 -41996 -57723 [cited 2023 Jun 15]. 5. COP26 health programme. Country commitments to build climate resilient and sustainable health systems. Geneva: World Health Organization; 2021. Available from: https:// cdn .who .int/ media/ docs/ default -source/ climate -change/ cop26 -health -programme .pdf [cited 2023 Jun 15]. 6. Climate change: exacerbating poverty and inequality. In: World social report 2020. Inequality in a rapidly changing world. New York: United Nations; 2020. Available from: https:// www .un .org/ development/ desa/ dspd/ wp -content/ uploads/ sites/ 22/ 2020/ 02/ World -Social -Report2020 -FullReport .pdf [cited 2023 Jun 15]. 7. Pörtner HO, Roberts DC, Tignor M, Poloczanska ES, Mintenbeck K, Alegría A, et al. Climate change 2022: impacts, adaptation and vulnerability. Working group II contribution to the sixth assessment report of the intergovernmental panel on climate change. Cambridge: Cambridge University Press; 2022.Available from: https:// www .ipcc .ch/ report/ ar6/ wg2/ downloads/ report/ IPCC _AR6 _WGII _FrontMatter .pdf [cited 2023 Jun 15]. 8. Sherman JD, MacNeill AJ, Biddinger PD, Ergun O, Salas RN, Eckelman MJ. Sustainable and resilient health care in the face of a changing climate. Annu Rev Public Health. 2023 Apr 3;44(1):255–77. doi: http:// dx .doi .org/ 10 .1146/ annurev -publhealth -071421 -051937 PMID: 36626833 9. Blom IM, Asfura JS, Eissa M, Mattijsen JC, Sana H, Haines A, et al. A systematic review protocol for identifying the effectiveness of greenhouse gas mitigation interventions for health care systems in low- and middle- income countries [version 2; peer review: 1 approved, 1 approved with reservations]. Wellcome Open Res. 2022;7:202. doi: http:// dx .doi .org/ 10 .12688/ wellcomeopenres .18005 .2 10. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. doi: http:// dx .doi .org/ 10 .1136/ bmj .n71 PMID: 33782057 11. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. PRISMA-P Group. Preferred reporting items for systematic review and meta- analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015 Jan 1;4(1):1. doi: http:// dx .doi .org/ 10 .1186/ 2046 -4053 -4 -1 PMID: 25554246 12. JBI. Critical appraisal tools [internet]. Adelaide: JBI; 2023. Available from: https:// jbi .global/ critical -appraisal -tools [cited 2023 Aug 27]. 13. Bell M, Greenberg MR. Climate change and human health: links between history, policy, and science. Am J Public Health. 2018 Apr;108 S2:S54–5. doi: http:// dx .doi .org/ 10 .2105/ AJPH .2018 .304437 PMID: 29698093 14. Haines A, Epstein PR, McMichael AJ. Global health watch: monitoring impacts of environmental change. Lancet. 1993 Dec 11;342(8885):1464–9. doi: http:// dx .doi .org/ 10 .2105/ AJPH .2018 .304437 PMID: 29698093 15. Blom I. Annexes to: A systematic review to identify the effectiveness of greenhouse gas mitigation interventions for health-care systems in low- and middle-income countries. [data repository]. London: London School of Hygiene & Tropical Medicine; 2023. doi: http:// dx .doi .org/ 10 .17037/ DATA .00003678 16. Theory of change concept note. New York: United Nations Sustainable Development Group Latin America and the Caribbean; 2016. Available from: https:// unsdg .un .org/ sites/ default/ files/ 16 . -2016 -10 -18 -Guidance -on -ToC -PSG -LAC .pdf [cited 2023 Aug 27]. 17. Rasheed FN, Baddley J, Prabhakaran P, De Barros EF, Reddy KS, Vianna NA, et al. Decarbonising healthcare in low and middle income countries: potential pathways to net zero emissions. BMJ. 2021 Nov 9;375:n1284. doi: http:// dx .doi .org/ 10 .1136/ bmj .n1284 PMID: 34753746 18. Mateen FJ, Oh J, Tergas AI, Bhayani NH, Kamdar BB. Titles versus titles and abstracts for initial screening of articles for systematic reviews. Clin Epidemiol. 2013;5:89–95. doi: http:// dx .doi .org/ 10 .2147/ CLEP .S43118 PMID: 23526335 19. Grafakos S, Trigg K, Landauer M, Chelleri L, Dhakal S. Analytical framework to evaluate the level of integration of climate adaptation and mitigation in cities. Clim Change. 2019;154(1-2):87–106. doi: http:// dx .doi .org/ 10 .1007/ s10584 -019 -02394 -w 20. Chowdhury T, Chowdhury H, Hasan S, Rahman MS, Bhuiya MMK, Chowdhury P. Design of a stand-alone energy hybrid system for a makeshift health care center: a case study. J Build Eng. 2021;40:102346. doi: http:// dx .doi .org/ 10 .1016/ j .jobe .2021 .102346 21. Duraivelu R, Elumalai N. Performance evaluation of a decentralized rooftop solar photovoltaic system with a heat recovery cooling unit. Environ Sci Pollut Res Int. 2021 Apr;28(15):19351–66. doi: http:// dx .doi .org/ 10 .1007/ s11356 -020 -12104 -0 PMID: 33398739 22. Isa NM, Das HS, Tan CW, Yatim AHM, Lau KY. A techno-economic assessment of a combined heat and power photovoltaic/fuel cell/battery energy system in Malaysia hospital. Energy. 2016;112:75–90. doi: http:// dx .doi .org/ 10 .1016/ j .energy .2016 .06 .056 23. Lemence ALG, Tamayao M-AM. Techno-economic potential of hybrid renewable energy systems for rural health units in the Philippines. World Med Health Policy. 2021 Mar 1;13(1):97–125. doi: http:// dx .doi .org/ 10 .1002/ wmh3 .388 24. Narang R, Deotale V, Narang P. Containment laboratory running on hybrid power sources: a solution for countries with limited access to electricity? Int J Tuberc Lung Dis. 2017 Apr 1;21(4):480. doi: http:// dx .doi .org/ 10 .5588/ ijtld .17 .0082 PMID: 28284275 25. Olatomiwa L, Blanchard R, Mekhilef S, Akinyele D. Hybrid renewable energy supply for rural healthcare facilities: an approach to quality healthcare delivery. Sustain Energy Technol Assess. 2018;30:121–38. doi: http:// dx .doi .org/ 10 .1016/ j .seta .2018 .09 .007 26. Paksoy HO, Andersson O, Abaci S, Evliya H, Turgut B. Heating and cooling of a hospital using solar energy coupled with seasonal thermal energy storage in an aquifer. Renew Energy. 2000;19(1):117–22. doi: http:// dx .doi .org/ 10 .1016/ S0960 -1481(99)00060 -9 27. Panwar NL, Kaushik SC, Kothari S. Thermal modelling and experimental validation of solar tunnel dryer: a clean energy option for drying surgical cotton. Int J Low Carbon Technol. 2016 Mar 1;11(1):16–28. doi: http:// dx .doi .org/ 10 .1093/ ijlct/ ctt053 28. Pina EA, Lozano MA, Serra LM. Assessing the influence of legal constraints on the integration of renewable energy technologies in polygeneration systems for buildings. Renew Sustain Energy Rev. 2021;149:111382. doi: http:// dx .doi .org/ 10 .1016/ j .rser .2021 .111382 29. Raghuwanshi SS, Arya R. Design and economic analysis of a stand-alone hybrid photovoltaic energy system for remote healthcare centre. Int J Sustain Eng. 2020 Sep 2;13(5):360–72. doi: http:// dx .doi .org/ 10 .1080/ 19397038 .2019 .1629674 30. Ali M, Wang W, Chaudhry N. Application of life cycle assessment for hospital solid waste management: a case study. J Air Waste Manag Assoc. 2016 Oct;66(10):1012–8. doi: http:// dx .doi .org/ 10 .1080/ 10962247 .2016 .1196263 PMID: 27268967 Research 175Bull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. Greenhouse gas mitigation interventions for health-care systems 31. Ciplak N. Assessing future scenarios for health care waste management using a multi-criteria decision analysis tool: a case study in the Turkish West Black Sea Region. J Air Waste Manag Assoc. 2015 Aug;65(8):919–29. doi: http:// dx .doi .org/ 10 .1080/ 10962247 .2015 .1038398 PMID: 26211633 32. Khan BA, Khan AA, Ali M, Cheng L. Greenhouse gas emission from small clinics solid waste management scenarios in an urban area of an underdeveloping country: a life cycle perspective. J Air Waste Manag Assoc. 2019 Jul;69(7):823–33. doi: http:// dx .doi .org/ 10 .1080/ 10962247 .2019 .1578297 PMID: 30831059 33. Khor HG, Cho I, Lee KRCK, Chieng LL. Waste production from phacoemulsification surgery. J Cataract Refract Surg. 2020 Feb;46(2):215– 21. doi: http:// dx .doi .org/ 10 .1097/ j .jcrs .0000000000000009 PMID: 32126034 34. Liu M, Wen J, Feng Y, Zhang L, Wu J, Wang J, et al. A benefit evaluation for recycling medical plastic waste in China based on material flow analysis and life cycle assessment. J Clean Prod. 2022;368:133033. [Internet]doi: http:// dx .doi .org/ 10 .1016/ j .jclepro .2022 .133033 35. Raila EM, Anderson DO. Black carbon emission reduction strategies in healthcare industry for effective global climate change management. Waste Manag Res. 2017 Apr;35(4):416–25. doi: http:// dx .doi .org/ 10 .1177/ 0734242X16678315 PMID: 27909212 36. Zakaria AM, Labib OA, Mohamed MG, El-Shall WI, Hussein AH. Assessment of combustion products of medical waste incinerators in Alexandria. J Egypt Public Health Assoc. 2005;80(3-4):405–31. PMID: 16900616 37. Zhao H-L, Wang L, Liu F, Liu H-Q, Zhang N, Zhu Y-W. Energy, environment and economy assessment of medical waste disposal technologies in China. Sci Total Environ. 2021 Nov 20;796:148964. doi: http:// dx .doi .org/ 10 .1016/ j .scitotenv .2021 .148964 PMID: 34273841 38. Ahmadzadehtalatapeh M, Yau YH. The application of heat pipe heat exchangers to improve the air quality and reduce the energy consumption of the air conditioning system in a hospital ward–a full year model simulation. Energy Build. 2011;43(9):2344–55. doi: http:// dx .doi .org/ 10 .1016/ j .enbuild .2011 .05 .021 39. Datta PK, Sinha R, Ray BR, Jambunathan V, Kundu R. Anesthesia maintenance with ‘induction dose only’ sevoflurane during pediatric ophthalmic examination: comparison with standard low-flow technique through a randomized controlled trial. Paediatr Anaesth. 2017 Feb;27(2):162–9. doi: http:// dx .doi .org/ 10 .1111/ pan .13040 PMID: 27900813 40. Sun Y, Huang Q. A comparative study of design strategies for lobby of outpatient department of hospital buildings in cold climate region in China. Procedia Eng. 2017;180:471–9. doi: http:// dx .doi .org/ 10 .1016/ j .proeng .2017 .04 .206 41. Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, et al. Cataract surgery and environmental sustainability: waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017 Nov;43(11):1391–8. doi: http:// dx .doi .org/ 10 .1016/ j .jcrs .2017 .08 .017 PMID: 29223227 42. Higgins JP, Savović J, Page MJ, Elbers RG, Sterne JA. Chapter 8: assessing risk of bias in a randomized trial. In: Higgins J, Thomas J, editors. Cochrane handbook for systematic reviews of interventions. 2nd edition. London: The Cochrane Collaboration; 2019. Available from: https:// training .cochrane .org/ handbook/ current [cited 2023 Aug 27]. 43. Siemieniuk R, Guyatt G. What is GRADE? In: BMJ Best Practice [internet]. London: BMJ Publishing Group Limited; 2022. Available from: https:// bestpractice .bmj .com/ info/ toolkit/ learn -ebm/ what -is -grade/ [cited 2023 Aug 27]. 44. World Bank country and lending groups data [internet]. Washington, DC: The World Bank; 2021. Available from: https:// datahelpdesk .worldbank .org/ knowledgebase/ articles/ 906519 -world -bank -country -and -lending -groups [cited 2021 Dec 2]. 45. Central Electricity Authority. CDM CO2 baseline database. Version 18.0. New Delhi: Government of India Ministry of Power; 2023. Available from: https:// cea .nic .in/ cdm -co2 -baseline -database/ ?lang = en [cited 2023 Aug 27]. 46. Takahashi K, Louhisuo M. IGES list of grid emission factors. Hayama: Institute for Global Environmental Strategies; 2023. Available from: https:// www .iges .or .jp/ en/ pub/ list -grid -emission -factor/ [cited 2023 Aug 27]. 47. Cox S, Hotchkiss E, Bilello D, Watson A, Holm A. Bridging climate change resilience and mitigation in the electricity sector through renewable energy and energy efficiency: emerging climate change and development topics for energy sector transformation. Washington, DC: National Renewable Energy Laboratory; 2017. Available from: https:// www .nrel .gov/ docs/ fy18osti/ 67040 .pdf [cited 2023 Aug 27]. 48. Chowdhury S, Pozzer A, Haines A, Klingmüller K, Münzel T, Paasonen P, et al. Global health burden of ambient PM2.5 and the contribution of anthropogenic black carbon and organic aerosols. Environ Int. 2022 Jan 15;159:107020. doi: http:// dx .doi .org/ 10 .1016/ j .envint .2021 .107020 PMID: 34894485 49. Lou XF, Nair J. The impact of landfilling and composting on greenhouse gas emissions–a review. Bioresour Technol. 2009 Jan;100(16):3792–8. doi: http:// dx .doi .org/ 10 .1016/ j .biortech .2008 .12 .006 PMID: 19155172 50. Gautam M, Agrawal M. Greenhouse gas emissions from municipal solid waste management: a review of global scenario. In: Muthu SS, editor. Carbon footprint case studies: municipal solid waste management, sustainable road transport and carbon sequestration. Singapore: Springer; 2020. pp. 123–60. doi: http:// dx .doi .org/ 10 .1007/ 978 -981 -15 -9577 -6 _5 51. Hess JJ, Ranadive N, Boyer C, Aleksandrowicz L, Anenberg SC, Aunan K, et al. Guidelines for modeling and reporting health effects of climate change mitigation actions. Environ Health Perspect. 2020 Nov;128(11):1–10. doi: http:// dx .doi .org/ 10 .1289/ EHP6745 PMID: 33170741 52. Hunter RF, Hassan S, Whitmee S, Haines A. A call for natural experiment guidance for planetary health. BMJ. 2023 Mar 28;380:668. doi: http:// dx .doi .org/ 10 .1136/ bmj .p668 PMID: 36977514 53. Alliance for transformative action on climate and health (ATACH) [internet]. Geneva: World Health Organization; 2023. Available from: https:// www .who .int/ initiatives/ alliance -for -transformative -action -on -climate -and -health [cited 2023 Nov 27]. 54. Drew J, Christie SD, Rainham D, Rizan C. HealthcareLCA: an open-access living database of health-care environmental impact assessments. Lancet Planet Health. 2022 Dec;6(12):e1000–12. doi: http:// dx .doi .org/ 10 .1016/ S2542 -5196(22)00257 -1 PMID: 36495883 Research Greenhouse gas mitigation interventions for health-care systems ABull World Health Organ 2024;102:159–175B| doi: http://dx.doi.org/10.2471/BLT.23.290464 Iris Martine Blom et al. 175 continues... Box 3. Conceptual framework according to the theory of change on greenhouse gas mitigation interventions in health-care systems in low-and middle-income countries Problem statement Climate change is and will continue to affect human health through many different direct and indirect health outcomes. Less well-known is that health-care systems themselves contribute 4.4 % of global greenhouse gas emissions. Health-care systems, referring to the institutions, people and resources involved in delivering health care to individuals, need to implement mitigation interventions to ensure an adequate, effective and systematic response to these health effects while aiming for synergies or co-benefits with adaptation and, specifically, climate resilience. Since UNFCCC COP26, countries have committed to a more environmentally sustainable, low-carbon health-care system – out of which the majority are low- and middle-income countries. There is a lack of robust evidence guiding efforts towards environmentally sustainable health- care systems, particularly in low- and middle-income countries. Impact and aim If measures are taken to mitigate greenhouse gas emissions produced by health-care systems in low- and middle-income countries effectively, then: 1. the health-care systems could advance while contributing less to climate change; 2. a knock-on effect could potentially lead to a reduction in climate risk for health due to synergies or co-benefits for adaptation; and 3. raising awareness can indirectly help achieve local and national climate goals. This happens as people, communities, and other sectors, including high-income countries, become more informed about how climate change affects health. This knowledge can lead to better climate actions as well as improving climate plans by combining them with health strategies. Furthermore, the health-care sector can significantly guide and shape the actions of these various groups. Delivery assumptions: 1. Relevant interventions can be identified in the literature 2. Sufficient interest and dedication from policy-makers 3. Skills, abilities and resources are present. Assumptions about effects: 1. Improved health outcomes through interventions 2. Potential positive knock-on effect on adaptation 3. Potential indirect effect on awareness and local and national climate action. Possible unintended consequences 1. Conflict or trade-off mitigation intervention with adaptation or prioritization mitigation over adaptation when there is an urgent need to adapt. Theory of change process assumptions 1. Robust data and experts consulted 2. Theory of change is a living document. Outcomes, outputs and potential risk and barriers 1. Reduction of greenhouse gas emissions produced by health-care operations (emission scope 1). Key Indicator: percent reduction in greenhouse gas emissions. • Stimulate low carbon prescriptions • Increase efficiency and minimize patient travel, that is, through strategic planning and multidisciplinary consults • Transition to a health-care system of community-based health promotion and disease prevention with a prominent role of primary health care • Shift towards higher usage of eHealth, including teleconsultations • Stimulate the use of low carbon transport alternatives for operations, including low emission ambulances • Health workforce barriers including lack of adequately trained health workers might prevent multidisciplinary consults, a transition to preventive, primary health care • Lack of access to technology might prevent eHealth • Soft issues such as lack of support and awareness among staff, open dialogue and proper infrastructure to implement change. Note: Financial barriers or other accessibility barriers including patents might prevent low-carbon prescriptions or low-carbon transport alternatives. 2. Reduction of greenhouse gas emissions from energy used in health care (emission scope 2). Key Indicator: Percent of reduction in greenhouse gas emissions. • Transition to clean energy through renewable energy sources and low carbon grids • Use of batteries to expand the renewable energy supply • Use energy efficiently, such as light-emittin diode (LED) fixtures • Soft issues, including lack of support and awareness among staff or suppliers, lack of open dialogue, and lack of proper infrastructure to implement change. Note: Financial barriers or other accessibility barriers including lack of expertise might prevent a transition to clean and renewable energy, use of battery power or energy efficient products such as LED lighting. Greenhouse gas mitigation interventions for health-care systems 175B Iris Martine Blom et al. Research Bull World Health Organ 2024 ; 102 : 159–175B| doi: http://dx.doi.org/ 10.2471/BLT.23.290464 ...continued COP: Conference of Parties; LED: light-emitting diode; UNFCC: United Nations Framework Convention on Climate Change. Note: Adapted from Rasheed et al., 2021.17 3. Reduction of greenhouse gas emissions of health-care supply chains (emission scope 3). Key Indicator: Percent of reduction in greenhouse gas emissions. • Reuse of medical devices and supplies • Reduce the acquisition of non-reusables and high-emission alternatives and increase the use of low-emission alternatives • Transition to a predominantly plant-based hospital menu with locally-produced foods (e.g. for staff and visitors) • Stimulate health and care workers and patients to minimize transport and, when necessary, use active transport or electric, shared vehicles • Use low-emission alternatives for transportation and distribution • Encourage low-emission travel options for business travels • Procure from net-zero suppliers or suppliers with a strategy to move to net-zero • Food system effects or food availability might prevent a transition to plant-based hospital menus with locally-produced food • Soft issues, including lack of support and awareness among staff or suppliers, lack of open dialogue, and lack of proper infrastructure to implement change. Note: Financial barriers or technological limitations might prevent reuse of supplies, low-emission prioritization in acquisitions, low-emission alternatives for transportation or distribution, low-emission travel options, and procuring from net-zero suppliers. 4. Co-benefit or synergy of the mitigation intervention with actions contributing to climate change adaptation. Key Indicator: Percent of reduction in loss of life or disability. • Hospital-wide passive heating and cooling system • Agriculture on hospital rooftops • Soft issues, including lack of support and awareness among staff and/or leadership, lack of open dialogue, and lack of proper infrastructure to implement change. Note: Financial barriers due to specified or allocated funding, lack of flexibility of funding and gaps in knowledge.