https://orcid.org/0000-0001-6663-4389
Figures
Abstract
According to the WHO 2021 Health and Climate Change Global Survey Report, most countries’ climate change and health plans are witnessing low to moderate implementation due to (among other reasons) insufficient funding, evidence, research, and multisectoral collaboration. In Ghana, the national climate change agenda has, for over two decades, consistently prioritised its health systems, but progress is slow due to underfunding, inconsistent policies and poor mainstreaming in health system polices - “thick mainstreaming”. This study examined how Ghana’s national-level climate-resilient health systems agenda has translated to building climate-resilient Primary Healthcare (PHC) systems and identified existing barriers to further mainstreaming. In this mixed-method study, 27 District Health Management Team members (82%) %) from 3 PHC systems and 65 PHC facilities (HCF) managers (98%) from three low-resourced districts/PHCs participated in vulnerability assessments of their respective PHC and HCF using the WHO checklist. Key informant interviews were conducted and thematically analysed to explore facilitators and barriers to mainstreaming climate change action into PHC operations. The vast majority (82%) of PHCs observed multiple climate hazards. PHC systems showed incomplete preparation or medium risk with an average score of 2.3. Eighty-three per cent of PHC facilities were unprepared (unable to respond or at higher risk) for the recorded impacts of climate hazards such as storms, heatwaves, floods, droughts and wildfires. Key informants reported the mainstreaming of the national climate agenda into PHC policies and programs as facilitators, but limited human resource capacity, financing, and weak subnational inter-sectoral collaboration were reported as barriers. Based on these findings, Ghana’s national climate agenda has not adequately translated into the development of climate-resilient PHC systems. We recommend investments in capacity development and in mainstreaming Ghana’s national climate agenda into PHC operational policies, protocols, and standards, with inbuilt monitoring mechanisms to catalyse sustainable climate action within PHC amidst scarce resources.
Citation: Abugnaba-Abanga R, Doke DA, Browne J, Downward G, Otsuki K (2026) Translating national climate policies to resilience actions at the subnational level in low resource settings: Lessons from Ghana’s health systems. PLOS Clim 5(3): e0000779. https://doi.org/10.1371/journal.pclm.0000779
Editor: Teodoro Georgiadis, Institute for BioEconomy CNR, ITALY
Received: November 19, 2025; Accepted: February 16, 2026; Published: March 5, 2026
Copyright: © 2026 Abugnaba-Abanga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: In accordance with the ethical requirements of this study, only the principal investigator has access to the original de-identified data; therefore, raw and individual data cannot be shared publicly. Aggregated and de-identified data are available upon reasonable request from the University for Development Studies (UDS), Ghana, which serves as the data custodian. The dataset is currently deposited in the University for Development Studies, Ghana data repository (UDSspace) at http://udsspace.uds.edu.gh/jspui/handle/123456789/4559, and access request maybe directed to the UDS Library/Repository Office at library@uds.edu.gh.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The World Bank estimates that climate change could drag more than one hundred million people back into extreme poverty by 2030, with a substantial part of this reversal attributable to negative impacts on health [1]. These health impacts include both the consequences of heatwaves [2] as well as the consequences of other extreme weather events, including impacts on mental health [3–5] and changing patterns of communicable diseases [6,7], resulting in increasing pressure on primary healthcare systems [8]. Despite global recognition of the impacts of climate change and health, the 2021 WHO health and climate change global survey reported that the majority of countries’ climate change and health plans are witnessing low to moderate implementation [9]. Bottlenecks to implementation include insufficient funding and budgets, research and evidence, prioritisation, multisectoral collaboration, and lack of engagement of health actors in in-country processes [9,10], and the lack of mainstreaming of climate action to health systems policies and standards, known as “thick mainstreaming” [11] The 2022 report of the Lancet Countdown on Health and Climate Change argues that adopting the “Health Centred Approach” to climate change policy offers an opportunity for a low-carbon and resilient future. The report further suggests that the first step towards achieving this ambition is to develop context-specific responses to strengthen health systems, which are essential for protecting populations from the negative impacts of climate change. [12].
Climate change will disproportionately impact the Global South [13]. For example, extreme weather events caused damage worldwide, totalling approximately US$253 billion in 2021, particularly in countries with a low Human Development Index [12]. In Africa, extreme weather events affected 19 million people and caused 4,000 deaths in 2022 [14]. In Ghana, hydrometeorological events have affected over 16 million people and caused 400 deaths in the last 50 years [15]. Secondly, climate change is shrinking Ghana’s forest and transition zones [16], with future projections suggesting that climate change will widen health(care) inequities and intensify pressure on Ghana’s health budget due to increased climate-sensitive diseases and extreme climate events [17].
The government of Ghana initiated action to enhance the adaptation of its health system to climate change in 2010. These efforts culminated in the implementation of a pilot climate change and health project, which was implemented by the Ministry of Health (MOH), with support from its development partners, from 2010 to 2015. This pilot aimed to develop systems and response mechanisms to mainstream climate change risk management into the health sector [18]. Furthermore, the MOH mainstreamed change adaptation into the Health Sector’s Medium-term Development Plans (HMDP) for the years 2010–2013 and 2014–2017 [19,20]. Subsequently, Ghana developed a National Climate Change Policy led by an inter-ministerial National Climate Change Committee, which estimated the cost of adaptation actions, and recommended budget allocations by its health ministry for climate action [21]. In 2020, Ghana’s MOH updated its healthcare waste management policy to enhance sustainable waste management by healthcare facilities [22].
Since 2010, Ghana’s national-level climate change policy documents have underscored the need to address climate change and health. The National Climate Change Adaptation Strategy 2010–2020 [23] envisaged decentralised planning, implementation, and monitoring at the sub-national level through broad intersectoral collaboration. Specific to health systems, it emphasised the need to build health workers’ capacity, upgrade existing healthcare facilities, promote modern information management systems, and strengthen rapid disaster response teams to cope with climate change health-related challenges. Ghana’s National Climate Change Master Action Programs for Implementation 2015–2020 dedicated policy action six to climate change and health. The masterplan developed a mechanism for mainstreaming climate action into health systems and recommended increasing the number of functional Community-Based Health Planning and Services (CHPS) to scale up existing interventions for effective management of associated risk and effects of climate change. The plan incorporated fixed implementation timelines alongside monitoring and evaluation plans [24].
Amidst the increasing threats of climate change to health systems in Ghana, and the lack of data on health system vulnerabilities [25], this study examined how Ghana’s national-level climate-resilient health systems agenda has translated into the building of climate-resilient PHCs and identified existing barriers to further mainstreaming. The study also aims to inform health systems policymakers, researchers, and local government authorities on how to improve PHC systems adaptation and further the national agenda for health systems adaptation to climate change.
Materials and methods
Ethical statement
This study underwent scientific and ethical review and received approval from the Navrongo Health Research Centre Internal Review Board, Ghana, on the 9th of September 2022 (Approval ID: NHRCIRB 478). Participant recruitment and data collection were from the 9th of September 2022 to the 8th of November 2022. Participation was voluntary. Before participating in this study, participants read a participant information brief that outlined the study’s purpose, methods, time requirements, inclusion criteria, participant responsibilities, benefits and risks, and confidentiality. Additionally, participants were given time to seek clarification, and they were informed of their unfettered freedom to discontinue participation in the study at any stage of the interview. Participants who agreed to participate signed a written consent form.
Study area
As shown in Fig 1, this study was conducted in the Upper East Region (UER) of Ghana. This region is prone to multiple extreme weather events [26,27], resulting in reduced access to water and food and disruption of health services, with restricted access and health service delivery in resource-deprived, hard-to-reach communities [17,28]. The region has poor geographic access to health facilities and points of care (including diagnostics) [29,30], high poverty rates [31], intermittent outbreaks of climate-sensitive conditions like cerebrospinal meningitis [32], zoonotic diseases, e.g., anthrax [33,34], and endemic malaria [35]. The UER has fifteen administrative districts that are coterminous with PHCs. PHCs are key implementation units of Ghana’s health systems. A PHC is overseen by a District Health Management Team (DHMT) headed by a district director. Healthcare services are delivered through a network of Community-Based Planning and services (CHPS), with a mandate for close-to-client services, health centres that serve as referral points for CHPS, and a district hospital serving as the top referral facility within the PHC structure.
Map constructed using QGIS (2024), version 3.40. Administrative boundary data obtained from GADM (Global Administrative Areas), version 4.1, Ghana level 0. Shapefile downloaded from https://gadm.org/download_country.html. Data used under the GADM Academic License (https://gadm.org/license.html), which permits use of derived maps in academic publications, including those published under CC BY.
Study design
The study utilised mixed methods, involving vulnerability and impact assessment of PHCs and PHC facilities using WHO guidance and checklist, and Key informant interviews using adapted Consolidated Framework for Implementation Research Index (CFIR Index) interview guides to understand context-specific facilitators and barriers to mainstream climate change adaptation and mitigation into PHC operations.
The WHO operational framework for building climate -resilient health systems [36] recommends mainstreaming climate-resilient and environmental sustainability components into the six health systems building blocks: leadership and governance, health workforce, health information systems, essential medical products and technologies, service delivery, and climate financing. To enhance implementation and system -wide approaches, the WHO provided further guidance on measuring the climate-resilience of the health system [37], building climate -resilient and environmentally sustainable healthcare facilities [38] and a checklist for assessing the climate-resilient and environmental sustainability of healthcare facilities [39]. The checklist supports health facility managers in conducting vulnerability and impact assessments and climate-resilient and environmentally sustainable planning for Workforce, WASH and healthcare waste, Energy, and Infrastructure, technology, products and processes, which are essential to the functioning and optimal operation of healthcare facilities.
To explore context-specific facilitators to mainstreaming climate change adaptation and mitigation into PHC operations, we adapted open-ended key-informant interview guides and the Index dimensions of the CFIR Index [40], an adaptation of the CFIR [41]. Index dimensions were maintained, but questions were tailored to focus on PHC adaptation and mitigation using the WHO frameworks for building climate-resilient health systems as a benchmark (S1 Text). Table 1 highlights the adaptations made to the CFIR Index dimension. The CFIR Index evaluates barriers and facilitators in the implementation of evidence-based practices. It comprises four dimensions and 29 sub-dimensions. The CFIR Index utilises qualitative data with responses rated on a 5-point scale ranging from -2 (Barrier) to +2 (Facilitator). As part of the adaptation to the CFIR Index, the study utilised thematic analysis rather than quantifying responses.
Sampling
Multi-stage sampling [42] was adopted for field research because PHCs are standardised [43] and are guided by the same policies and standards. PHCs are subnational or district health systems modelled around three-tier healthcare facility levels comprising Community-Based Health Planning and Services (CHPS), health centres, district hospitals, and a District Health Management Team (DHMT), which is headed by a district director of health services who is responsible for healthcare services in the District/PHC.[44,45].
The current study utilised the pre-existing health systems clustering [46] of East [which is the Bawku Area and Kusasi speaking group and consists of six districts (Bawku Municipal, Bawku West, Binduri, Garu, Tempane and Pusiga]; Central [which is the Grune speaking group and consists of five Districts [Bolgatanga Municipal, Bolgatanga East, Talensi, Nabdam and Bongo]; and West [which is the Kasena-Nankana and Buili speaking areas and contains four Districts [Kasena-Nankana West, Kasena-Nankane Municipal, Builsa North and South] [46]. Binduri, Talensi, and Builsa North Districts were randomly selected from the East, Central, and West clusters, respectively.
Study participants
All members of the District Health Management Team (DHMT) and all PHC facility managers in the study districts were invited to participate in vulnerability assessments of PHC systems and PHC healthcare facilities, respectively. Between the 31st of October and the 25th of November 2022. District Directors of Health Services (DDHS) of each PHC were purposively sampled for interviews on facilitators and barriers to mainstreaming climate change adaptation and mitigation into PHC operations. After interviewing the directors, they recommended experienced PHC facility managers for further interviews. Participant eligibility was based on their in-depth knowledge of the operations of PHCs and health sector policies and guidelines [47].
Quantitative data collection
The current study utilised the World Health Organisation frameworks for building and assessing climate-resilient health systems [37,48,49] to assess the climate resilience of PHC systems and healthcare facilities (CHPS, health centres/clinics, district hospitals). The WHO frameworks were chosen because they provide tools for system-wide assessment of PHCs [50] and are recommended by the Ghana government [24].
PHC system.
The study adapted the suggested checklist within the WHO framework for measuring the climate resilience of health systems [37] by removing questions targeting national health systems and restricting the checklist to short-term risk (less than ten years). The restriction to short-term was because PHC managers typically implemented interventions guided by health system policies with a typical cycle of 5–10 years. Secondly, the short-term indicators were deemed more realistic and contextually relevant, as PHC managers lacked the capacity to assess long-term risk. Participants’ reasoning aligns with the WHO guidance, which acknowledges that indicator suitability can vary across global, regional, and local scales. A “remarks´ column was also created for participants to provide further context around their answers (S2 Text). District Health Management Team (DHMT) members from the participating PHCs or Districts attended a half-day, district-based orientation on the framework and data collection tool. Following the orientation, participants conducted the assessments in their respective spaces/offices. During the assessment, the researcher was on-site to clarify questions and concerns that arose. Each DHMT member then assessed their respective PHCs individually. Participants answered the checklist questions using a 3-level scale: (3) Unprepared; unable to respond or unavailable; (2) incomplete or basic preparation or in progress; and (1) prepared; achieved or completed as prescribed by the WHO.
PHC facilities.
The WHO checklist for assessing climate resilience and environmentally sustainable healthcare facilities in the context of climate change was used for assessments [49]. First, researchers visited each participating PHC facility and administered a hazard identification template to PHC facility managers to determine which climate hazards their health facilities had been exposed to between September 2021 and September 2022. After analysing and determining healthcare facility-specific hazards, the responding managers were invited to participate in a two-day district-based orientation and vulnerability assessment of their respective healthcare facilities. All risks were evaluated using three options: (3) Unprepared or high risk, (2) Incomplete preparation or medium risk, and (1) Prepared or low risk, as recommended by the WHO checklist. The WHO checklist focuses on the healthcare facility components of Health Workforce: Water, Sanitation, Hygiene and Healthcare waste; Energy; and Infrastructure, Technology, products, and processes. To minimise bias, each PHC facility manager was provided with a participant information brief approved by the ethics committee that outlined the study objectives, methodology, confidentiality, and anonymity. They were then given the opportunity to seek individual clarification, after which they voluntarily signed before the hazard identification phase. Additionally, prior to vulnerability assessments, it was reiterated that the exercise was not an audit and that only aggregated analysis would be used publicly. Emphasis was placed on basing the assessment on working knowledge of health facilities. The researcher was available during scoring solely to clarify questions, not to influence ratings.
Qualitative data collection
Key-informant interviews.
The current study adapted the Consolidated Framework for Implementation Research (CFIR) Index [40] interview guides to explore PHC managers’ views on facilitators and barriers to mainstreaming the WHO frameworks for climate change adaptation and mitigation into PHC operations. The guides were based on questions exploring the suitability of the WHO framework for PHC, PHC systems and stakeholders, PHC programming culture and PHC managers’ identification with the WHO framework (supplementary material 2). At the beginning of the interviews, a PowerPoint presentation was used to refresh participants’ knowledge of the relevant WHO frameworks [37,48–50].
Data analysis
Quantitative data analysis.
The vulnerability of each PHC system was determined by calculating the average score of the individual assessments of all participating DHMT members. Based on the average score, we classified the level of climate resilience into 3 (unprepared), 2 (incomplete preparation or medium risk) or 1 (prepared). Similarly, the average score from each health facility checklist was used to classify the level of vulnerability into three options: (3) Unprepared or high risk, (2) Incomplete preparation or medium risk and (1) Prepared or low risk. Even though the WHO checklist does not provide consolidated scoring like similar indexes [51] The study used the average score per assessment to help participants gain a clearer understanding of the overall preparedness or vulnerability of their respective PHCs and healthcare facilities. To address inter-rater differences, we compared individual DHMT member assessments for outliers, but we did not identify any extreme results. However, we did not find extreme results. To further manage rater differences, we calculated the average of each PHC’s individual DHMT scores to arrive at a district/PHC position.
Qualitative data analysis.
The analysis of qualitative data involved the verbatim transcription of eighteen audio recordings of key informant interviews. Transcriptions were coded by thoroughly reading data, identifying issues, reflecting on their meanings, and capturing them as codes. We developed a codebook containing descriptions of the issues and their context, considering breadth, depth, and nuance. Finally, emerging themes were identified from the codes [52].
Positionality statement: Although the researcher had collaborated with some PHCs in the past, he had no managerial authority within the participating PHCs or their facilities. The researcher’s familiarity with PHC systems and earlier visits to PHCs and their facilities during community entry and hazard identification built trust and promoted open dialogue, thereby minimising potential power dynamics. The researcher’s role during the assessment was primarily to clarify questions about the checklist. To improve independence, facility managers used spaces they deemed convenient.
Results
Study participants
Table 2 presents the study participants’ categories. Sixty-five PHC facility managers (97%) participated in vulnerability assessments (Binduri 19, Builsa North 21, and Talensi 25), and 27 District Health Management Team members (82%) participated in vulnerability assessments of their respective PHCs (Binduri 8, Builsa North 10, and Talensi 9). Eighteen PHC and district health facility managers participated in interviews (1 District Director of Health Services and 5 PHC facility managers per district).
PHC systems
Table 3 presents an overview of the PHC systems’ reported climate resilience across the three districts. PHC systems showed incomplete preparation or medium risk, with an average score of 2.3 (Binduri 2.2, Builsa North 2.4, and Talensi 2.2). The average scores for ten components ranged from 2 (integrated risk and early warning systems, management of environmental determinants of health, climate-informed programming) to 2.7 (health & climate change research), indicating that, overall, PHCs were incompletely prepared (2.3) to respond to climate exposures.
Variations existed between the ten components. According to respondents, PHCs were unprepared in the components of the health and climate change research agenda (with an average of 2.6 in Binduri, 2.9 in Builsa North, and 2.5 in Talensi), climate health financing (average 2.5), and workforce (average 2.5). PHCs were incompletely prepared(medium risk) in the component of integrated risk and early warning (2), management of environmental determinants of health (2), climate-informed programming (2), emergency preparedness and management (2.2) and vulnerability and capacity assessment (2).
PHC facilities
Exposure/observed climate hazards by PHC facilities.
Table 4 presents the types and numbers of observed impacts from climate hazards within PHC facilities between September 2021 and September 2022. Healthcare facilities in Builsa North and Talensi observed storms, heatwaves, floods, droughts, and wildfires, while Binduri observed only storms, heatwaves, and floods. Of the 65 PHC facilities surveyed, 82% (n = 53) were exposed to multiple climate hazards between September 2021 and September 2022.
As shown in Table 4, A total of 143 climate hazards were reported across all PHC facilities in one year, with an average of 2.2 hazards per facility, which was stable across areas (Binduri: 2.1, Builsa North: 2.2, Talensi: 2.3. PHC facilities observed a total of forty-eight storm-related hazards (34%), twenty-five heatwave-related hazards (25%), twenty-four flood-related hazards (17%), twenty-two drought-related hazards (15%) and thirteen wildfire-related hazards (9%). Refer to S1 Table.
Vulnerabilities of PHC facilities.
Fig 2, presents the degree to which the PHC facilities are prepared against, or vulnerable to, the observed climate hazards. Overall, the healthcare facilities were highly vulnerable to climate hazards, with none completely prepared or able to respond to the observed hazards (i.e., lower risk). Instead, 83% of PHC healthcare facilities are unprepared or unable to respond (higher risk) to observed climate hazards(n = 118), while 17% (had basic or incomplete preparation(n = 25) and hence had the capacity for only a low-level response to the impacts of storms, heatwaves, floods, droughts and wildfires (Medium risk).
Vulnerability of PHC Facilities by component.
Table 5 presents the preparedness or vulnerability of PHC facilities and specific healthcare facility components, including Workforce, WASH and healthcare waste, Energy, and Infrastructure, technology, and processes. Overall, 93% of CHPS were unable to respond (higher risk) to 100 out of 108 exposures (93%), while health centres were unable to respond (higher risk) to 18 out of the 31 exposures (58%). In contrast, all hospitals show basic or incomplete preparation (medium risk). The following sections outline the vulnerabilities of the four components of PHC facilities, crucial to building climate-resilient, environmentally sustainable healthcare facilities.
Workforce: The workforce of all categories of PHC facilities is unable to respond to observed climate hazards or exposures. CHPS showed a higher risk to 69% of exposures (n = 75). Health centres showed a higher risk to 59% of exposures (n = 16). On the contrary, the hospital health workforce showed no higher risk from their exposures.
WASH and healthcare waste: When examining the preparedness of the WASH and healthcare waste components, CHPS and health centres were prepared (i.e., low risk) against 1 exposure each. By contrast, hospitals did not show lower risk in this component but showed higher risk to 1 exposure. CHPS showed the highest risk to 82% of exposures (n = 89), and health centres showed higher risk to 42% of exposures (n = 13).
Energy: In the energy systems component, no hospitals showed a higher risk (unable to respond) to their exposures (n = 4). CHPS showed a higher risk (unable to respond) to 89% of exposures (n = 96), and health centres showed a higher risk (unable to respond) to 48% of exposures (n = 15).
Infrastructure, technology, products and processes: In the infrastructure, technology, products and processes component, no CHPS or hospitals were able to respond or lower health risk to the exposures. Health centres showed lower risk (responded or were prepared) to 6% of exposures (n = 2). CHPS were unable to respond (higher risk) to 89% of exposures (n = 96), health centres were unable to respond to 68% of exposures (n = 21), and 50% of hospitals were unable to respond (higher risk) to exposures (S2 Table).
Facilitators and barriers to mainstreaming climate change adaptation and mitigation.
Participants reported that climate change adaptation and mitigation align with the vision and mission of the Ministry of Health and the Ghana Health Service. They suggested that pursuing PHC adaptation and mitigation could enhance the safety of both clients and staff and promote quality of care. Participants identified benefits of adopting the WHO framework, including prompt detection of climate-sensitive diseases, improved infection control, enhanced staff capacity to address emerging health system challenges, promotion of new and appropriate technology to support proper and standard care, and improved access to a complete range of healthcare services during disasters and emergencies.
Facilitators.
Six main themes were identified as facilitators of furthering climate change adaptation and mitigation: policy mainstreaming, active leadership, multi-sectoral collaboration, partnerships, prioritising new projects and programmes, and workforce capacity.
Policy mainstreaming of the national climate change agenda into health system policies, protocols, standards and accountability mechanisms, a recommendation we call “thick mainstreaming,” was reported as crucial for climate action within PHC. For instance, one participant remarked:
“Policy, you know, we here actually don’t; we only make decisions to sometimes inform policy. We don’t build up policy, we implement the policy, so once the Ghana Health Service structure accepts or adopts this as a policy [mainstream climate change adaptation and mitigation] for the implementation, we are there to implement it” [Participant, 13].
Another participant remarked that:
Policy will influence because, if it [mainstreaming adaptation and mitigation] is not in line with Ghana Health Service or the Ministry of Health policies, there will be conflicting interests. [Participant 2].
The participants emphasised the importance of policies, standards, and protocols in shaping PHC operations. Participants suggested that mainstreaming climate action into PHC policies, standards, and protocols would support system-wide enforcement through monitoring, reporting, and periodic evaluations. This, we call “Thick mainstreaming”, would strategically trigger a system-wide response to climate change adaptation and mitigation within the PHCs.
Participants reported that active leadership could support the mainstreaming and successful implementation of adaptation and mitigation efforts. A participant’s remark on the importance of leadership in any mainstreaming efforts was:
“I will say leadership; if they are not showing leadership, it will affect the implementation because, if you do not have that leadership to ensure sustainability, especially in the implementation stage, there is no sustainability. They [the leadership] will finish implementing the whole thing, and you will go back to zero.” [Participant 2]
Participants emphasised the need for PHC leadership to collaborate with other health-determining sectors and the community to ensure successful mainstreaming and implementation, as PHC systems will require the support of these stakeholders to implement effectively. The participants acknowledged the importance of a multisectoral approach involving subnational or local government actors. A participant further remarked that:
“Whether it is developed by us or in collaboration, it will depend on how well we link up with the other sectors to understand the impact of it on health systems” [Participant 2].
The participants emphasised the need to secure “buy-in” from subnational actors because of their contribution to the operations of PHCs. To emphasize the need for buy- in of other stakeholders. Another participant remarked that:
“If all stakeholders are brought on board and are ready to do the right thing: that is, the community is giving us good land, contractors are adhering to standards, we are sending the right staff and equipment, and there is monitoring and supervision, it will work” [Participant 7].
Building the PHC workforce’s capacity to understand the nexus between climate change and health was identified as important for mainstreaming climate action into PHC operations. Participants noted that the availability of a good mix of health staff could provide a foundation for the mainstreaming process, but emphasised the need for their buy-in through a comprehensive, system-wide capacity-building process. To illustrate, a participant remarked:
“So, it is the ability to explain the relationship between climate change and health for the health staff, especially leadership, to understand first, then the acceptability will be okay. [Participant 2]”
Another view on the capacity of the workforce was the need to integrate climate change and health into the curriculum of health training institutions. This view recommends integrating climate change and health considerations into the training curriculum for health professionals to ensure long-term sustainability. As a participant remarked:
“So, I think that climate change can be incorporated into our health training institutions so from day one, once you enter into any health institution before you come out, you are made aware of what climate change is” [Participant 16].”
Participants reported that collaborations with decentralised government departments, e.g., the National Disaster Management Organisations (NADMO), to undertake climate-resilient actions will enhance sustainability and stakeholder buy-in. Collaborations with NADMO and other decentralised departments were reported to be ad hoc, with mostly no formal plans, designated officers, or budgets. A participant from one of the DHMTs, in justifying his score during the vulnerability assessment, remarked that:
“Health emergency committees (are) in place, but (there are) no budgets and plans” [DHMT member].
Partnerships with NGOs were reported as crucial for mainstreaming climate action into PHC operations. NGOs are already leading autonomous adaptation and mitigation efforts in WASH and healthcare waste through capacity building and the provision of appropriate infrastructure. They underscored the importance of NGOs for innovation and resources in PHC systems and acknowledged the need to include and build partnerships with NGOs to enhance PHC adaptation and mitigation efforts. A participant remarked that:
“We have a partner [an NGO] in the district that is supporting us in terms of WASH and infection prevention control, so they provide us with water, toilet facilities, bathrooms and incinerators” [Participant 7].
New projects and programs were reported as potential entry points for mainstreaming climate change adaptation and mitigation within PHC. Proponents of this view suggest that PHC systems can take advantage of new donor or government of Ghana-funded projects and programs to mainstream resilience actions, learn lessons and institutionalise. They suggest that PHCs’ financial constraints require a staggered approach, starting with new projects. Other participants were of the view that, benefits associated with mainstreaming climate considerations into newly funded projects can enhance acceptability among PHC actors. Two participants remarked that:
“For example, as I said, the service has a standard of a building or infrastructure for the CHPS facility; if implementing this, there is a need for an addition, then it should start from the new ones” [Participant 2].
“I think if mainstreaming climate change adaptation and mitigation in PHC is a success and clients come for services, it’s a motivation. I think they (PHC actors) will be motivated” [Participant 4].
Barriers.
Five themes were identified as barriers to the effective mainstreaming of climate change adaptation and mitigation into PHC operations: costs, vertical/top-down projects, complexity, inappropriate community entry, and health and workforce constraints.
Costs associated with mainstreaming are reported as a barrier due to the low revenue-generating capacity of PHC facilities. Some participants reported that PHC facilities could not sustain the mainstreaming of climate action into their operations due to their poor financial state and therefore needed external support to initiate and sustain action. Some participants reported that PHC facilities can mainstream non-capital-intensive activities, such as communication and awareness, if their capacity is built. However, mainstreaming is perceived as resource-intensive (human, financial, technological, and other), complicating mainstreaming efforts given the scarcity and competition for resources. A participant observed:
The challenge regarding cost is that we are already handicapped due to low internally generated funds and late reimbursement of NHIS; hence, a deprived health facility like ours cannot work on climate change measures without extra support” [Participant 3].
Even though cost is reported as a barrier, hospitals reported undertaking autonomous adaptations in WASH, healthcare waste, and energy systems by acquiring small water systems and standby generators. All hospitals participating in the study reported financing these adaptations from their own income. A participant reported that:
“For instance, I think some years ago, we used to depend on the community water supply. So, there were times there was no water, we decided to build a mechanised borehole, so for some years now, we have been having water supply every day in the year” [Participant 9].
Participants reported top-down approaches or vertical programs as a barrier to mainstreaming. Participants suggest that any mainstreaming efforts must involve all levels of PHC actors. Two participants reported that:
“Apart from the capacity, sometimes they do not make the implementers or those who are supposed to use the policy own the policy. The policy is developed somewhere; I do not have any idea about it, and they push it down to me and say implement it, so sometimes, if you do not own the policy, it becomes difficult for you to even commit to implementing it” [Participant 15].
“Sometimes it has to do with funding; when programs come, the real implementers of the program are left out. So, when the funding stops, then they will now be pushing the one who was not actually trained to continue. In that sense, you will be reluctant” [Participant 14].
Some participants reported that mainstreaming efforts will be complex due to the need for buy-in from local government and informal actors, such as communities and traditional authorities, which might not necessarily perceive climate change adaptation and mitigation as a priority. For instance, a participant observed:
For me, I think the four approaches are okay. We might not need to make any changes when it comes to the four approaches, but we may have to first let the people understand the essence and impact of climate change, and when they buy into the idea, I think that we will be” [Participant 8].
Participants underscored the need for in-depth community entry and a participatory process to ensure that internal and external PHC stakeholders, especially staff, clearly understand the nexus between climate change and health and the need to proactively mainstream climate change into PHC operations. They reported that poor community entry and stakeholder participation would hinder mainstreaming climate change adaptation and mitigation into PHC.
“I think that receptivity will be good, but depending on the entry process, if people have that understanding of the benefits it will have on the healthcare systems, they will accept it” [Participant 2].”
Limited staffing and current workloads were identified as constraints to mainstreaming. Participants reported that mainstreaming climate change adaptation and mitigation into PHC would worsen their workloads and lead to inefficiency unless PHC recruits additional staff. A participant remarked that:
“For me, I will say maybe it might be a little harder when it comes to staffing because as [it is] now, we don’t have enough staff and the workload is there, so if this policy comes to add and it has to add more load on what I am already having and there isn’t enough staff to maybe share the work, I think that one will also not make it ineffective”[Participant 18].
Discussion
Even though Ghana’s national climate change agenda underscores the importance of health sector adaptation [24] and mitigation [22,53], these policies have not adequately translated into mainstreaming climate resilience in Primary Healthcare (PHC) operations in the low-resourced setting of Northern Ghana. Despite substantial exposure of PHC healthcare facilities to multiple climate hazards, PHC managers identified low human resource capacity on the nexus between climate change and health systems, cost, and weak subnational inter-sectoral collaboration as barriers to mainstreaming. PHC managers also identified systematic mainstreaming climate change adaptation and mitigation into PHC policies, protocols and standards with an inbuilt accountability mechanism- “thick mainstreaming”, leadership commitment, improved sub-national multi-sectoral collaboration, NGOs and improved workforce capacities as important facilitators.
Ghana’s National Climate Change Adaptation Framework Plan [54] and Climate Change Master Plan 2015–2020 [24] underscore the need to mainstream climate action into health system policies. The Master Plan developed a mainstreaming methodology to assist the health system in mainstreaming climate action at all levels of planning. However, these national-level policies and plans have not been further mainstreamed into health system and PHC policies, resulting in limited climate action in PHC operations. This finding aligns with Tye and Waslander (2021), who suggest that sectoral policy inconsistency has led to poor mainstreaming of climate action in health sector policies, resulting in limited climate action within the health sector [55]. The poor mainstreaming of climate action into health systems policies and programmes may have implications for climate action within PHCs across the country, as PHCs share the same structure and mandate, with their operations guided by health systems policies. [45].
PHCs are the primary operating unit of the Ghanaian health system, accounting for over half of essential public health services, and are at the forefront of managing public health emergencies related to natural disasters [45]. This presupposes that mainstreaming climate action into PHC policies and standards is crucial for moving from policy to action at the subnational level. Despite the current challenges, mainstreaming climate action into PHC policy and systems will trigger innovation and autonomous adaptation within PHC, such as new training, infrastructure, and new partnership models that integrate climate considerations. This finding aligns with Mogelgaard et al (2018), who argue that, for countries to bridge the implementation gap for adaptation, they must achieve the five levers of leadership, policy frameworks, information and tools, coordination mechanisms, and financial processes [56]. For example, Ghana’s Integrated Disease Surveillance and Response guidelines [57] are fully mainstreamed into PHC systems, resulting in their full adoption and integration into the health management information systems of PHC and its facilities [58]. This example illustrates how mainstreaming climate action into PHC policies and standards with inbuilt accountability mechanisms can trigger system-wide action, and how essential capacity to mainstream climate action into PHC may already be present.
PHC system preparedness
PHC systems in the three study districts show incomplete preparedness (medium risk) to climate exposures compared to 83% of PHC facilities that show a higher risk. Participants from the District Health Management Committee (DHMT) of PHCs credited collaborations with NGOs for climate action. For instance, NGOs were credited for the preparedness (low risk) of a few lower-level healthcare facilities in the components of WASH and healthcare waste (1% of CHPS, 3% of health centres/clinics) and infrastructure, technology, products, and processes (6% of health centres/clinics). The Health Sector Waste Management Policy, which was developed in 2020 [22] provided a framework and guidance for these collaborations and interventions. Collaborations with decentralised government departments and the National Disaster Management Organisation (NADMO) are cited in the development of emergency preparedness plans for disease outbreaks and natural disasters. These collaborations provide a springboard for bottom-up approaches, buy-in and ownership by PHC actors, and the infusion of context-specific knowledge and experience into the future health system agenda on climate action. We recommend that health system policymakers adopt and encourage decentralised and bottom-up approaches for future mainstreaming efforts.
Incomplete preparation (medium risk) of PHC had not translated into deepening climate action in the operations of the majority of PHC facilities they supervised. For instance, 93% of community-level CHPS (community-based clinics focused on close-to-client services) and 58% of higher-level health centres or clinics to which CHPS refer within the PHC system were unprepared (i.e., unable to respond or at higher risk) to observed climate hazards. The inability of PHC systems to translate their resilience, capacity, and associated knowledge into PHC facilities is primarily due to the ad hoc nature of existing collaborations, which contributes to a disconnect between PHC and PHC facilities’ capacities and preparedness. These collaborations may not always align with formal plans, budgets, knowledge dissemination, support, and monitoring systems of PHCs, thereby creating difficulties in translating PHC system capacities into practice by healthcare facilities. Even though these partnerships are enhancing climate action within PHC, we argue that they are not sustainable due to the short-term nature of donor funding. They lack a system-wide approach with institutional integration, and limited learning and scale-up opportunities due to poor transition management. This view was reinforced by a participant who suggested that capacity-building for climate change adaptation should target lower-level PHC facilities from inception to enhance sustainability. We recommend that PHC broaden these collaborations to involve health research and training institutions to undertake implementation research to enhance scale-up efforts, and that the government take steps to integrate planetary health into training curricula for long-term sustainability, as observed by a participant. The integration of planetary health into (para)medical curricula also encourages various professional bodies and health care professionals to adequately prepare for climate-related challenges and to show leadership for sustainable climate action in PHC operations [59–63]. Secondly, mainstreaming climate action into PHC operations requires a shift in mindset and systems. This shift requires PHC to develop and incorporate into its systems a strategy to help build and stabilise intersectoral climate action. Such system-wide sustainability transitions have been conceptualised as inherently tension-ridden, as illustrated in the ‘X-curve’ developed by Dercks et al. While building better, more sustainable health systems, the existing systems need to be systematically destabilised to allow sustainable alternatives to emerge and institutionalise, while undesirable (i.e., unsustainable) practices of the past phase out [64]. As such, health system policymakers and others responsible for the transition need to engage a diverse set of PHC stakeholders to gather support and build momentum.
PHC facility preparedness
Despite the observed multiple exposures of PHC facilities to extreme weather events linked to climate change, such as storms, heatwaves, floods, wildfires, and droughts, 83% were reported to be unprepared (higher risk) for these events. The risk level differs by the size of the health facilities, with the larger healthcare facilities generally at lower risk: All district hospitals, the most developed and resourced facilities within PHC [65] showed moderate risk (incomplete preparation), compared with 58% of health centres/clinics and 93% of community-based healthcare CHPS facilities, which are unprepared (higher risk). The low revenue-generating capacity of lower-level healthcare facilities (CHPS and health centres) poses significant challenges for autonomous adaptation, as they depend heavily on erratic financial allocations. The situation presupposes that policymakers need to identify a funding mechanism for active PHC adaptation and mitigation. This finding aligns with the views of Tye and Waslander (2021), who identified funding as a significant challenge for progress in health system adaptation in Ghana [55]. On the contrary, hospitals financed autonomous adaptations from their revenues because they generate higher incomes [65]. For instance, interview participants from hospitals reported acquiring backup generators and localised water systems from their revenues.
Hospitals show greater resilience in the energy component (none of the hospitals in the current study were identified as having a higher risk), primarily because of their ability to finance adaptation measures. The acquisition of diesel-powered generators provides the necessary backup to ensure the provision of essential healthcare services when challenges arise with the national grid. Even though these investments in fossil-fuel-dependent technology provide some level of energy security, they also contribute to hospitals’ carbon footprint. This calls for increased investments in green technology alternatives to meet the demands of healthcare facilities. For example, small solar units can be deployed to provide alternative power to critical hospital departments. Some CHPS and health centres/Clinics combined the national electricity grid with solar energy to maintain critical supplies and services. NGOs and central government projects largely financed these energy resilience efforts.
Infrastructure, technology, products, and processes are significantly unprepared (higher risk) across all categories of healthcare facilities (50% of hospitals, 68% of health centres, and 89% of CHPS). This is partly because most health centres and hospitals were constructed decades ago, providing an opportunity to couple maintenance cycles with the need for substantial investments to improve their resilience and sustainability. The Ministry of Health, through the CHPS policy, has improved and standardised the CHPS design [66,67], with an emphasis on adaptation to context. However, local government authorities do not use these designs because of the associated costs and appetite for quick fixes for political gains (as reported by respondents). The appetite for short-term gains by local government authorities results in a missed opportunity to incorporate context-specific climate considerations into projects, considering that CHPS is Ghana’s key strategy for attaining universal Health Coverage [45], and is witnessed a tremendous increase in numbers (63% or 2,086 facilities) between 2015 [68] and 2017 [69], coupled with the fact that local government authorities are continuously investing in CHPS; accounting for construction of 47.8% of them [70]. PHCs should deepen collaborations with their partners to improve understanding of the nexus between climate change and health through relevant collaborative and community-based structures, thereby securing buy-in from stakeholders for optimal investment to avert future costs.
Conclusion and policy implication
The inability of Ghana’s health system policymakers to mainstream Ghana’s national climate change and health systems agenda into PHC policies, protocols, standards, and guidelines, coupled with limited funding and capacity, largely accounts for the disconnect between the national agenda and PHC operations. Key recommendations include mainstreaming the national climate change and health systems agenda into health policies, protocols, and guidelines, with built-in monitoring, accountability, and participatory mechanisms. This approach, which we call “thick Mainstreaming”, will stimulate climate-sensitive investments in PHC by local government actors and through collective action, driven by trust and the willingness to invest in PHC. This approach will stimulate autonomous contextual adaptation and provide a framework for PHC to partner with NGOs, which are essential partners in the development of PHC systems. It can also enable PHC to identify potential co-benefits with health-determining sectors, engage community actors, and strengthen bottom-up approaches for sustainable action towards climate-resilient health systems. To enhance climate action within PHC operations, the first step would be for health systems policymakers to integrate climate action into health systems policies and standards, as PHCs operate in accordance with them.
Limitations
The authors acknowledge the difficulty of generalising the results of vulnerability assessments. Notwithstanding this, the results can be applicable to most settings in the five northern regions and to some transitional zones in the middle belt of Ghana, as they share similar ecological characteristics. The results of the vulnerability assessments are context-specific and may not be applicable to settings that experience different hazards.
Secondly, only PHC facility managers participated in the vulnerability assessments of their respective facilities because we believed they had a good understanding of their operations. Although the study highlighted the vulnerabilities of PHC facilities, more inclusive assessments involving teams of diverse staff from PHC facilities, especially district hospitals, would have enriched the findings. Nonetheless, PHC facility managers have rich experience and knowledge of their respective health facilities, and we believe their assessments are reflective of the vulnerabilities of their facilities.
Regarding key informant interviews, this study focused solely on PHC leadership. However, we believe their in-depth knowledge of PHC operations and policies, Ghana’s health systems, and first-hand application of the relevant WHO tools make their perspectives reflective of PHC systems. We focused on PHC managers because they are responsible for implementing health system policy. Although the study highlighted national-level facilitators and barriers, including perspectives from broader local government and policy-level actors, would have deepened understanding. Nonetheless, PHC managers have substantial experience with Ghana’s health-sector policy processes, and we believe the reported facilitators and barriers are likely to be relevant at the policy level. PHCs are standardised across the country and operate under the same policies, standards and programmes. Hence, we envisage that similar results could be obtained by replicating the same study approaches in other PHCs in Ghana. Future studies involving broader local government and national-level health system actors would further enhance understanding of this topic.
Supporting information
S1 Text. Adapted CFIR Index Key Informant Interview guide. Semi-structured interview guide used to conduct key informant interviews for the study.
https://doi.org/10.1371/journal.pclm.0000779.s001
(DOCX)
S2 Text. Adapted checklist for assessing the climate resilience of PHC systems. A semi structured tool used to assess the climate resilience of Primary Healthcare Systems in study districts.
https://doi.org/10.1371/journal.pclm.0000779.s002
(DOCX)
S1 Table. Type and number of hazard exposure of PHC facilities by District. Detailed results underlying Table 4, showing the types of hazards to which Primary Healthcare facilities were exposed to, across the study districts.
https://doi.org/10.1371/journal.pclm.0000779.s003
(XLSX)
S2 Table. Expanded results of PHC facility vulnerability (preparedness). Detailed results underlying Table 5, presenting overall preparedness of PHC health facilities by type and component-specific vulnerabilities across the health workforce, water, sanitation, hygiene (WASH), and healthcare waste, energy, and infrastructure, technology, and processes.
https://doi.org/10.1371/journal.pclm.0000779.s004
(XLSX)
Acknowledgments
We express our gratitude to the Epper East Regional Health Directorate for granting us permission to undertake this study. We also acknowledge the district directors of health services and their managers for their active participation in this study despite their tight schedules.
References
- 1.
International Bank for Reconstruction and Development/The World Bank. Low-Carbon and Resilience Strategies for the Health Sector [Internet]. 2017. Available from: www.worldbank.org
- 2. Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Belesova K, Boykoff M, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. The Lancet. 2019;394(10211):1836–78.
- 3. Saltzman LY, Hansel TC, Ferreira RJ. Climate change and health equity: expanding our reach using technology. PLOS Clim. 2023;2(7):e0000242.
- 4. Corvalan C, Gray B, Villalobos Prats E, Sena A, Hanna F, Campbell-Lendrum D. Mental health and the global climate crisis. Epidemiol Psychiatr Sci. 2022;31:e86. pmid:36459133
- 5.
World Health Organization. Mental health and Climate Change: Policy Brief Key points [Internet]. 2022 [cited 2025 May 21]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://iris.who.int/bitstream/handle/10665/354104/9789240045125-eng.pdf?sequence=1
- 6. Franklinos LHV, Jones KE, Redding DW, Abubakar I. The effect of global change on mosquito-borne disease. Lancet Infect Dis. 2019;19(9):e302–12.
- 7. Ross ME, Wright AH, Luke M, Tamba A, Hessou HR, Kanneh S, et al. Household survey on climate change and human health in a low-income country: Associations between increased health emergencies and extreme changes in climate in Liberia. PLOS Clim. 2023;2(10):e0000286.
- 8. Lokotola CL, Mash R, Naidoo K, Mubangizi V, Mofolo N, Schwerdtle PN. Climate change and primary health care in Africa: a scoping review. J Climate Change Health. 2023;11:100229.
- 9.
WHO. 2021 WHO health and climate change global survey report [Internet]. 2021 [cited 2025 May 21]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://iris.who.int/bitstream/handle/10665/348068/9789240038509-eng.pdf?sequence=1
- 10.
World Health Organization. 2018 WHO Health and Climate Change Survey Report Tracking Global Progress [Internet]. 2019. Available from: http://apps.who.int/bookorders
- 11.
Abugnaba-Abanga R. Rethinking investments in climate-resilient and environmentally sustainable health systems: perspectives from Africa. [Internet]. Speaking of Medicine and Health. 2023 [cited 2025 Feb 4]. Available from: https://speakingofmedicine.plos.org/2023/11/09/rethinking-investments-in-climate-resilient-and-environmentally-sustainable-health-systems-perspectives-from-africa/
- 12. 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. The Lancet. 2022;400(10363):1619–54.
- 13. Carlson CJ, Alam MS, North MA, Onyango E, Stewart-Ibarra AM. The health burden of climate change: a call for global scientific action. PLOS Clim. 2023;2(1):e0000126.
- 14. Moyo E, Nhari LG, Moyo P, Murewanhema G, Dzinamarira T. Health effects of climate change in Africa: a call for an improved implementation of prevention measures. Eco Environ Health. 2023;2(2):74–8. pmid:38075293
- 15.
Environmental Protection Agency. Ghana’s Fourth National Communications to the United Nations Framework Convention on Climate Change [Internet]. 2020. Available from: www.epa.gov.gh
- 16. Yamba EI, Aryee JNA, Quansah E, Davies P, Wemegah CS, Osei MA, et al. Revisiting the agro-climatic zones of Ghana: a re-classification in conformity with climate change and variability. PLOS Clim. 2023;2(1):e0000023.
- 17.
Ministry of Environment Science Technology and Innovation. Ghana National Climate Change Policy [Internet]. Accra, Ghana; 2013 [cited 2025 May 22]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://faolex.fao.org/docs/pdf/gha169292.pdf
- 18.
GoG/UNDP. Integrating Climate Change Into the Management of Priority Health Risks in Ghana | UNDP Climate Change Adaptation [Internet]. 2010 [cited 2025 May 22]. Available from: https://www.adaptation-undp.org/projects/integrating-climate-change-management-priority-health-risks-ghana
- 19.
Ministry of Health. Health Sector Medium-Term Development Strategy 2010 – 2013. | FAOLEX [Internet]. 2010 [cited 2025 May 22]. Available from: https://www.fao.org/faolex/results/details/en/c/LEX-FAOC175088/
- 20.
Ministry of Health. Health Sector Medium Term Development Plan 2014-2017. Accra, Ghana: Ministry of Health; 2014.
- 21.
Asante FA, Bawakyillenuo S, Bird N, Canales TN, Tagoe CA, Ashiabi N. Climate change finance in Ghana [Internet]. 2015. Available from: http://www.odi.org.uk/projects/2537-climate-finance-climate-change-fast-start-finance
- 22.
Ministry of Health. Health Care Waste Management Policy for Ghana [Internet]. 2020 [cited 2025 May 22]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.moh.gov.gh/wp-content/uploads/2021/04/HEALTH-CARE-WASTE-MANAGEMENT-POLICY-Final.pdf
- 23.
GoG/UNEPUNDP. National Climate Change Adaptation Strategy. | FAOLEX [Internet]. 2010 [cited 2025 May 22]. Available from: https://www.fao.org/faolex/results/details/fr/c/LEX-FAOC174398/
- 24.
Ghana National Climate Change Policy Action Programme for Implementation: 2015–2020 - weADAPT [Internet]. [cited 2025 May 22]. Available from: https://weadapt.org/knowledge-base/national-adaptation-planning/ghana-national-climate-change-policy-action-programme/
- 25.
Climate risk country profile: Ghana - Ghana | ReliefWeb [Internet]. [cited 2025 May 22]. Available from: https://reliefweb.int/report/ghana/climate-risk-country-profile-ghana
- 26. Owusu AB, Fynn IEM, Adu-Boahen K, Kwang C, Mensah CA, Atugbiga JA. Rate of desertification, climate change and coping strategies: Insights from smallholder farmers in Ghana’s Upper East Region. Environ Sustain Indic. 2024;23:100433.
- 27. Smits WK, Attoh EMNAN, Ludwig F. Flood risk assessment and adaptation under changing climate for the agricultural system in the Ghanaian White Volta Basin. Climatic Change. 2024;177(3).
- 28. Dotse-Gborgbortsi W, Dwomoh D, Asamoah M, Gyimah FT, Dzodzomenyo M, Li C, et al. Dam-mediated flooding impact on outpatient attendance and diarrhoea cases in northern Ghana: a mixed methods study. BMC Public Health. 2022;22(1):2108. pmid:36397017
- 29. Kuupiel D, Adu KM, Bawontuo V, Mashamba-Thompson TP. Geographical accessibility to district hospitals/medical laboratories for comprehensive antenatal point-of-care diagnostic services in the Upper East Region, Ghana. EClinicalMedicine. 2019;13:74–80.
- 30. Kuupiel D, Adu KM, Apiribu F, Bawontuo V, Adogboba DA, Ali KT, et al. Geographic accessibility to public health facilities providing tuberculosis testing services at point-of-care in the upper east region, Ghana. BMC Public Health. 2019;19(1):718. pmid:31182068
- 31.
Cooke E, Hague S, Andy M. The Ghana Poverty and Inequality Report: Using the 6th Ghana Living Standards Survey [Internet]. 2016 [cited 2025 May 22]. Available from: https://catalog.ihsn.org/citations/64923
- 32. Akanwake JB, Atinga RA, Boafo YA. Effect of climate change on cerebrospinal meningitis morbidities and mortalities: a longitudinal and community-based study in Ghana. PLOS Clim. 2022;1(8):e0000067.
- 33. Oduoye MO, Scott GY, Dave T, Bolanle AHH, Mwinbong AD, Modupeoluwa OO. One health approach to mitigate anthrax in Ghana. Health Sci Rep. 2024;7(1).
- 34.
Aminu TG. Upper East Region: Anthrax outbreak leads to ban on the sale of cattle in some communities - Ghana Fact. 2023 [cited 2025 May 22]; Available from: https://ghanafact.com/upper-east-region-anthrax-outbreak-causes-ban-on-sale-of-cattle-in-some-communities/
- 35. Ayamba EY, Dzotsi EK, Dormechele W, Ansah NA, Bangre O, Nyuzaghl JA-I, et al. Evaluation of seasonal malaria chemoprevention implementation in the Upper East region of Northern Ghana. Malar J. 2025;24(1):123. pmid:40234957
- 36.
World Health Organisation. Operational framework for building climate resilient health systems [Internet]. World Health Organisation; 2015. pp. 47. [cited 2025 Feb 4]. Available from: https://www.who.int/publications/i/item/operational-framework-for-building-climate-resilient-health-systems
- 37.
World Health Organisation. Measuring the climate resilience of health systems [Internet]. 2022 [cited 2025 May 24]. Available from: https://www.who.int/publications/i/item/9789240048102
- 38.
World Health Organisation. WHO Guidance for Climate-Resilient and Environmentally Sustainable Healthcare Facilities. 2020.
- 39.
World Health Organisation. Checklists to Assess Vulnerabilities in Health Care Facilities in the Context of Climate Change. 2021.
- 40.
Assefa M, McGovern M. The Consolidated Framework for Implementation Research (CFIR) Index Manual for Administration and Scoring CFIR Index. CFIR Index Manual. 2019.
- 41. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. pmid:19664226
- 42. Taherdoost H. Sampling methods in research methodology; how to choose a sampling technique for research. SSRN Electron J. 2016.
- 43.
Parliament of Ghana. Ghana Health Service and Teaching Hospitals Act, 1996 (Act 525) [Internet]. 1996. Available from: https://lawsghana.com/post-1992-legislation/table-of-content/Acts%20of%20Parliament/GHANA%20HEALTH%20SERVICE%20AND%20TEACHING%20HOSPITALS%20ACT,%201996%20(ACT%20525)/138#google_vignette
- 44.
Government of Ghana. Ghana Health Service and Teaching Hospital -ACT525. 1996.
- 45.
Ministry of Health. Ghana’s Roadmap for Attaining Universal Health Coverage 2020-2030 [Internet]. Accra, Ghana; 2020. Available from: https://www.moh.gov.gh/wp-content/uploads/2021/08/UHC-Roadmap-2020-2030.pdf
- 46.
PHS/NHRC. Hidden cost to utilisation of reproductive health services in the Upper East Region of Ghana [Internet]. 2016 [cited 2025 May 22]. Available from: https://drive.google.com/drive/u/0/home
- 47. Flick U. The SAGE Handbook of Qualitative Data Analysis [Internet]. 2014 [cited 2025 May 29]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ufs.ac.za/docs/librariesprovider68/resources/methodology/uwe_flick_(ed-)-_the_sage_handbook_of_qualitative(z-lib-org)-(1).pdf?sfvrsn=db96820_2
- 48.
World Health Organization. WHO guidance for climate resilient and environmentally sustainable health care facilities [Internet]. 2020 [cited 2025 May 24]. Available from: https://www.who.int/publications/i/item/9789240012226
- 49.
World Health Organization. Checklists to Assess vulnerabilities in Health Care Facilities in the Context of Climate Change [Internet]. 2021 [cited 2025 May 24]. Available from: https://www.who.int/publications/i/item/9789240022904
- 50.
World Health Organisation. Operational framework for building climate resilient health systems [Internet]. 2015 [cited 2025 May 24]. Available from: https://www.who.int/publications/i/item/operational-framework-for-building-climate-resilient-health-systems
- 51. Organisation PAH. Hospital Safety Index: Guide for Evaluators. 2nd ed. 2019. pp. 148–73. [cited 2025 May 24]. Available from: https://iris.paho.org/handle/10665.2/51448
- 52.
Hennink M, Hutter I, Bailey A. Qualitative Research Methods. 2nd ed. In: Owens A, Bush C, editors. London: SAGE; 2020.
- 53.
Ministry of Health. National Health Policy [Internet]. Accra, Ghana; 2020. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.moh.gov.gh/wp-content/uploads/2021/08/NHP_January-2020.pdf
- 54.
Ghana’s National Adaptation Plan Framework - NAP Global Network [Internet]. [cited 2025 May 24]. Available from: https://napglobalnetwork.org/resource/ghana-nap-framework/
- 55.
Tye S, Waslander J. Mainstreaming Climate Adaptation Planning and Action into Health Systems in Fiji, Ghana, and Benin. World Resources Institute; 2021.
- 56. Mogelgaard K, Dinshaw A, Ginoya N, Preethan P, Waslander J. From planning to action: mainstreaming climate change adaptation into development contents. 2018. Available from: https://www.wri.org/
- 57.
GoG/Ministry of Health. Integrated Disease Surveillance and Response in Ghana [Internet]. 2002 [cited 2025 May 25]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.moh.gov.gh/wp-content/uploads/2016/02/Integrated-Disease-Surveillance-and-Response-Ghana-Guidelines.pdf
- 58.
Ghana Health Service. Health Information Management System Standard Operating Procedures. 4th Ed. 2020 [cited 2025 May 25]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ghimaghana.org/resources/STANDARD%20OPERATING%20PROCEDURE(SOP)%204th%20edition.pdf
- 59. Pendrey CG, Chanchlani S, Beaton LJ, Madden DL. Planetary health: a new standard for medical education. Med J Aust. 2023;219(11):512–5. pmid:37949607
- 60. Shaw E, Walpole S, McLean M, Alvarez-Nieto C, Barna S, Bazin K, et al. AMEE consensus statement: planetary health and education for sustainable healthcare. Med Teach. 2021;43(3):272–86. pmid:33602043
- 61. Leal Filho W, Eustachio JHPP, Paucar-Caceres A, Cavalcanti-Bandos MF, Nunes C, Vílchez-Román C, et al. Planetary health and health education in Brazil: towards better trained future health professionals. Int J Environ Res Public Health. 2022;19(16):10041. pmid:36011675
- 62. Oudbier J, Sperna Weiland NH, Boerboom T, Ravesloot JH, Peerdeman S, Suurmond J. An evidence-based roadmap to integrate planetary health education into the medical curriculum. Med Teach. 2022;:1–5. pmid:36395753
- 63. Irlam J, Reid S, Rother HA. Education about planetary health and sustainable healthcare: A national Delphi panel assessment of its integration into health professions education in South Africa. Afr J Health Prof Educ. 2024;16(1):e327.
- 64. Hebinck A, Diercks G, von Wirth T, Beers PJ, Barsties L, Buchel S, et al. An actionable understanding of societal transitions: the X-curve framework. Sustain Sci. 2022;17(3):1009–21. pmid:35069918
- 65. Wang H, Otoo N, Dsane-Selby L. Ghana National Health Insurance Scheme. Improving Financial Sustainability Based on Expenditure Review. 2017.
- 66.
GoG/Ministry of Health. National Community-Based Health Planning and Services(CHPS) Policy [Internet]. 2016 [cited 2025 May 25]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ghs.gov.gh/wp-content/uploads/2022/10/CHPS-POLICY.pdf
- 67.
Ghana Health Service. Community-Based Health Planning and Services National Implementation Guidelines [Internet]. 2016 [cited 2025 May 25]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ghs.gov.gh/wp-content/uploads/2022/10/National-CHPS-Implementation-Guidelines-Final-Version-ZNS-13022017.pdf
- 68.
Ghana Health Service. The Health Sector in Ghana Facts and Figures 2015 [Internet]. 2015 [cited 2025 May 25]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.moh.gov.gh/wp-content/uploads/2017/07/Facts-and-figures-2015.pdf
- 69.
Ghana Health Service. The Health Sector in Ghana Facta and figures 2018 [Internet]. 2018 [cited 2025 May 25]. Available from: https://www.scribd.com/document/375031363/FACTS-FIGURES-2017-pdf
- 70.
Kwame YB, Letsa T, Asor ME, Odame-Ankrah E. Progress of Community-based Health Planning and Services in Ghana [Internet]. 2019. Available from: www.globalscientificjournal.com