African district-level health facilities and services face many challenges including infectious disease outbreaks, conflict and insecurity, fiscal austerity, population displacement and climate-related hazards such as heat, flooding and drought.¹ These hazards rarely occur in isolation, but can be compound (multiple hazards occurring simultaneously), cascading (one hazard triggering or amplifying others) or interacting with existing social, economic and health system vulnerabilities to increase overall risk.² While emergency preparedness and disaster risk reduction plans often address acute shocks, they have not always adequately accounted for climate change as a current and intensifying risk multiplier – one that reshapes the frequency, severity and interaction of hazards already affecting primary care delivery.

Climate change is altering the burden and distribution of disease, changing the morbidity patterns seen in clinical practice.³ Climate hazards, such as heat waves, drought, wildfires, storms, cyclones and flooding, impact communities directly and place growing strain on the primary care facilities and primary hospitals that serve them. Facilities may be damaged or even destroyed by climate hazards, and healthcare workers may struggle to get to work or be stranded at the health facility. Essential services such as energy, water and sanitation may be disrupted, as well as the supply chain and communications. Facilities may also be required to operate under extreme temperatures that impact patients, healthcare workers and pharmaceutical supplies. Local populations may be displaced or suffer from climate-sensitive disease outbreaks, such as gastroenteritis or cholera. Healthcare workers are therefore often required to respond to acute climate-related emergencies while maintaining routine essential services, increasing operational pressure on already constrained health systems.

In their latest framework for health systems from a primary healthcare lens, the World Health Organization (WHO) identify three key components in service delivery.⁴ The model of care looks at what services are provided and how they are organised, key systems address quality improvement and patient safety, while the third area looks at the resilience of facilities and services. Resilience has usually been considered in relationship to infectious disease outbreaks and pandemics, but given the impact of climate change, climate resilienNote: The manuscript forms part of the themed collection titled ‘Continuing professional development for planetary health’, guest edited by Prof. Robert Mash.ce is also important.

Ironically, health systems also contribute to climate change through their own carbon emissions. Globally, the health sector contributes about 5% of emissions.⁵ While Africa’s absolute contribution is relatively small, the intensity of carbon per dollar of health spending is often high,⁶ reflecting inefficiencies in energy use, infrastructure and supply chains. If unaddressed, this creates a risk that future health system expansion will lock countries into high-cost, high-waste, fossil fuel-dependent models of care. For African health systems, this is not simply a question of environmental responsibility – it is a smarter development choice. Replicating the historical pathways of high-income countries has produced systems that are expensive to run, vulnerable to energy and supply shocks, and poorly adapted to climate stress. By contrast, consciously pursuing a low-carbon development pathway offers an opportunity to build health systems that are more affordable, more efficient and more resilient.

As countries work to strengthen the climate resilience of primary care facilities and services, environmental sustainability must be considered alongside resilience, not as an add-on but as a core design principle for future-ready health systems. In this article, we describe an approach to evaluating the climate resilience of our facilities and services with a focus on primary care and primary hospitals. The approach should culminate in an action plan. At the same time, we outline an approach to evaluating the carbon footprint and looking at ways of improving environmental sustainability. Family physicians often play a key role in leadership and need to contribute or even lead such initiatives.

Climate resilience has been defined as the ability to prepare for, respond to and recover from climate-related shocks and stressors.⁷ Recovery should ensure the facility returns to at least its baseline level of performance. A health system may learn from the experience and recover in a way that strengthens its performance and increases its resilience for future hazards. We describe a six-step process developed by the Climate Action Accelerator initiative and readers can refer to their online manual for more detail.⁸ The approach has been developed and field tested in low-resource and challenging situations such as a hospital in Chad and refugee camps in Bangladesh as well as primary care in South Africa:^8,9

This process can be followed for a single facility or several facilities in a subdistrict.

The underlying conceptual framework is shown in Figure 1. The process should identify the likely current and future climate hazards in the local area. The vulnerabilities and capacities of the facility and services to succumb to or withstand these hazards should be considered. Vulnerabilities are the factors that make a facility or service more likely to be harmed by a hazard (such as weak infrastructure, staff shortages or unreliable power or water supply). Capacities are the strengths, resources and systems that enable the facility to anticipate, withstand, respond to and recover from these hazards. The actual risks to the facility and services will depend on the climate hazards, their exposure to these hazards and how the impact of these hazards are modulated by the vulnerabilities and capacities. Once the risks are identified, then potential solutions can be listed to reduce these risks. A final action plan will prioritise the most feasible and effective solutions. You may need a small team to assist you in the process. Such a team should include the relevant managers and leadership.

The WHO consider climate resilience and environmental sustainability as two sides of the same coin as they both relate to the same set of key issues: the workforce; energy; water, waste, sanitation; infrastructure and equipment.⁷ These essential elements of the facility may be impacted by climate hazards, but also contribute to environmental impact and the carbon footprint. Solutions can improve both resilience and sustainability. Evaluating the carbon footprint may feel like a difficult and highly technical task. However, the organisation Health Care Without Harm (HCWH) have come up with a method and online tool that make the job relatively easy.¹⁰ The tool can also be downloaded as an Excel spreadsheet. The carbon footprint categorises the facility’s contribution to greenhouse gas emissions into three areas or scopes (Table 3).

Data need to be collected for each of the key items in Table 4, and more detail is given in the Manual.¹⁰ Some items may not be relevant and can be excluded from the calculation, while the data for other items may be too difficult to obtain. Commuting may need to be estimated based on a short survey with staff and patients. The more items that can be included, the more accurate the final footprint, but if items are excluded, this should be stated as a limitation of the final footprint report.

The HCWH Climate Impact Tool uses the data entered to calculate greenhouse gas emissions by applying emissions factors to each activity (such as fuel use, electricity consumption or travel). Where possible, these emissions factors are country-specific, reflecting local energy sources and conditions. If country-specific emissions factors are not available, global averages are used. The final carbon footprint can be presented as a total annual amount of carbon dioxide equivalent (eCO₂), an amount of eCO₂ per bed or per consultation and the proportions of the footprint allocated to different scopes (Figure 3). The analysis and reporting are automated by the online tool, reducing the technical burden for users. Importantly, the results are not intended to sit on a shelf. Healthcare Without Harm provides guidance and resources to help facilities identify priority areas for action and translate their carbon footprint into practical mitigation measures. These may include ‘quick wins’ – such as improving energy efficiency, reducing waste or changing procurement practices – as well as longer-term investments, such as transitioning to renewable energy, upgrading infrastructure or redesigning models of care. The footprint from the Cederberg (Figure 3) highlighted the potential for reducing the carbon footprint by changing the prescription of inhalers from metered dose to dry powdered inhalers. In this way, reducing the carbon footprint can directly inform the facility action plan, support environmental sustainability while also strengthening the resilience and efficiency of health services.

Family physicians and facility-level healthcare teams are well placed to lead practical action on climate resilience and environmental sustainability within primary care facilities and primary hospitals. This article describes practical steps to assess climate risks, identify priorities and develop facility-level action plans. At the same time, facilities can strengthen these efforts by considering their carbon footprint and adopting low-carbon development pathways. Taking an integrated approach – one that addresses resilience and sustainability together – can help protect patients, support healthcare workers and build stronger, more resilient and future-ready health services.