Introduction

It is a well-known fact that health systems have been destabilized by the effects of climate change worldwide. The World Health Organisation (WHO) defines a health system as all organizations, people, and actions whose primary intent is to promote, restore, or maintain health [1]. It is composed of the six building blocks, including service delivery, health financing, medical products, vaccines and technologies, human resources, health information, and leadership and governance, that interact as a unit to promote health outcomes [1]. Health systems are responsible for a wide range of healthcare services from community to health facility levels to promote good health for the population [2,3]. These responsibilities include health promotion, prevention, curative, and rehabilitation healthcare services, which require health systems to be resilient to the external forces, including climate change [3,4].

Resilience is the ability and agility of a system to change and flex according to circumstances, and continue to function under stress, while changing [5]. In this case, the WHO described health system resilience as the ability of all actors and their functions to collectively mitigate, prepare, respond, and recover from disruptive events while maintaining the provision of healthcare services to the population [6]. Resilient health systems are supported and characterized by their capacity to anticipate, respond to, cope with, recover from, and adapt to climate-related stress and shocks to sustainably improve population health, despite unstable conditions [7]. However, the majority of health systems have been impacted by the effects of climate change, which poses public health risks to the population globally [8,9].

Climate change (CC) is defined as the state of the climate identified statistically by changes in the mean and/or the variability of its properties that persist for an extended period, typically a decade or longer [10]. Its causes are directly related to human activities, such as deforestation and combustion of fossil and biomass fuels [11], resulting in greenhouse gas emissions that accumulate in the atmosphere [12,13]. It is manifested through an increase in average global temperature, directly linked to more frequent and prolonged extreme weather events [14]. CC has negatively affected health systems as it is associated with several public health risks. It expands geographical range for disease vectors, increases air and water pollution, exacerbates outbreaks of infectious diseases and extended drought periods, leading to food shortage and malnutrition [15–17]. Furthermore, CC-induced floods have been reported to destroy health system infrastructure, limiting access to healthcare services worldwide [18,19]. The most vulnerable to the effects of CC are health systems with less resilience due to low socioeconomic status, which cannot adapt and effectively respond to changes [20].

Geographically, CC is disproportionately impacting Sub-Saharan Africa (SSA) more than any other region globally. According to the World Bank, 42 out of 48 SSA countries are among the high-risk countries facing negative health outcomes resulting from the effects of CC [21]. The region is characterized by a high poverty level, socio-economic dependence, and increased burden of infectious diseases, lowering its ability to respond to the effects of CC [22,23]. Moreover, the SSA is continuously experiencing the occurrence of the CC extreme weather events, such as increased heat, droughts, changes in rainfall patterns, and floods [24]. The occurrence of extreme weather events in the SSA is associated with negative social and health outcomes, including infrastructure damage, food shortages, increased multiplication of infectious diseases, and loss of properties and lives [25,26]. So far, the region is considered a CC hotspot with strong physical and ecological effects on health, due to its poor socioeconomic status [27]. Furthermore, the majority of health systems in this region are usually overwhelmed by the increase in healthcare service demand immediately after the occurrence of CC extreme weather events [28]. Despite SSA being disproportionately affected, global evidence indicates that fewer efforts are made to develop strategies and responses that can enhance health systems to be resilient to CC events within the region [29,30]. As a result, the majority of health systems within the region are unable to respond effectively.

Therefore, this scoping review was conducted to map the available strategies and responses to the effects of CC within the SSA. Specifically, the review identified strategies and responses used to manage the effects of CC on health systems and identified the challenges faced when implementing the strategies and responses. The guiding research question for this scoping review was, “What are the health systems strategies and responses to the effects of climate change in Sub-Saharan Africa?” The research question was developed considering the Population, Concept, and Context (PCC) framework [31]. The lessons drawn from this review will increase the clarion call on health systems to invest more in CC response and adaptation plans within SSA countries [32].

Materials and methods

We conducted this scoping review in line with the methodological framework by Arksey & O’Malley updated by Peters [33,34], based on the following five stages: (i) research question identification, (ii) review of relevant studies, (iii) study selection, (iv) data charting, and (v) summarizing and reporting results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [35,36] (Supplementary Table 1) were followed to guide the reporting of the results for this scoping review. In addition, the protocol for this scoping review was registered with the Open Science Framework and has been published in a peer-reviewed journal [37].

Study selection

All searched articles were downloaded and exported into the Covidence software. The search yielded 11,459 articles, of which 2058 articles were identified as duplicates, which were removed internally by Covidence software. After title and abstract screening, 34 studies were retrieved for full-text article review. A further 26 were removed because they did not meet the eligibility criteria after full article review by the two reviewers. Eight studies were included for data extraction.

Two stages were implemented during the study selection process. The first stage involved determining study eligibility based on the inclusion criteria by reviewing the study titles and abstracts. This stage was conducted blindly by the two reviewers, who had an agreement level of over 95% on the articles to be reviewed in full using the Covidence software. All screening disagreements between the two reviewers were resolved by inviting the third reviewer. In the second stage, two reviewers independently read the identified articles to determine the availability of the desired outcomes. The reviewers agreed 100% after reading the full articles; as such, no third reviewer was required. Data extraction quality checks and supervision were conducted by the fourth reviewer. All these stages, including the development of the PRISMA flow diagram, were internally done using the Covidence software (Fig 1).

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Fig 1. The PRISMA flow diagram indicating number of articles identified, included, and excluded.

https://doi.org/10.1371/journal.pone.0349448.g001

Results

Discussion

This review mapped evidence on health systems strategies and responses to the effects of CC, as well as implementation-related challenges, in the SSA region. Based on our objectives, this review found existing evidence on the strategies and responses, as well as implementation challenges. Overall, the study has mapped strategies and responses across each of the six WHO building blocks of the health system. The majority of strategies and responses identified focus on governance and leadership, human resources, health information management, and service delivery, with little evidence on health financing and essential medical products, vaccines, and technologies. The review identified studies from different methodological approaches, including reviews, qualitative, quantitative, and mixed-method study designs. In addition, we identified available evidence on implementation challenges faced by the health systems that need to be addressed by all actors for effective CC responses across all six WHO building blocks of the health systems.

In this review, no study was identified outlining strategies and responses that comprehensively address all six WHO building blocks of the health system. All identified strategies and responses addressed specific building blocks of the health system, disregarding their interactions. This reveals a lack of a holistic approach when developing strategies and responses within SSA, which limits their effectiveness. In this case, unattended health system building blocks may indirectly reduce the effectiveness of strategies and responses, resulting in undesirable outcomes for the targeted building block. Similar findings were reported in another study on systems thinking in practice, the current status of the six WHO building blocks for health system strengthening in three districts of Zambia, which found that building block-specific weaknesses had a cross-cutting effect on other building blocks [47]. The isolated strategies and responses for the selected building blocks can lead to system failure, potentially increasing the vulnerability of health systems to CC [48]. Hence, the weakness in one of the six WHO building blocks of the health systems affects others [49], which is a vital component of a functioning system.

It is interesting to note that some of the identified health system strategies and responses include the use of health information. Elsewhere, the use of health information technologies has been reported to strengthen health systems’ ability to predict and project the occurrence of CC-related extreme events, which prompt preparedness for effective response [50]. In addition, another study reported that health information technologies, such as early warning systems, provide opportunities to detect potential health risks and aid early response preparedness before health hazards occur [50]. It further reported that if used properly, early warning systems may reduce financial costs and protect vulnerable health systems from catastrophic financial spending [50]. Furthermore, Rahimi-Ardabili et al. (2022), in their review on digital health for climate change mitigation and response, reported similar findings [51]. In addition, it is reported that integrating climate data into national health information systems aids better planning in case of future events [52].

On the other hand, the study has revealed that some countries are incorporating strategies and responses into existing national health policies and adaptation plans to further strengthen their health systems. This provides proof that some countries within the SSA region are taking the effects of CC seriously and are ready to find better solutions to build resilient health systems. In this regard, it is important to take note of the suggested guidelines and tools by Rios and Thomson (2024) when incorporating CC strategies and responses into existing national health policies and adaptation plans [53]. We assume that, if carefully incorporated, it will help health systems in the SSA region to be more resilient and be able to effectively respond to CC events.

This scoping review has revealed a few strategies and responses to strengthen medical products, vaccines, and technologies, and health financing mechanisms. This being the case, we assume that fewer decisions are made to enhance the health system’s capacity regarding medical products, vaccines, and technologies, and health financing when responding to CC events. Moreover, insufficient information on health finance implies that the majority of health systems within the SSA region depend on donated funds from partners, more especially from international donors, or redirect already available funds towards CC activities during the occurrence of extreme events [54]. Although this approach facilitates the continuous provision of healthcare services, it may result in partial implementation of CC-related activities if donors are reluctant or if funds to be redirected are not available. This might affect the health systems’ ability to cope with and recover from CC events. Similarly, other studies reported that little attention had been given to essential medical products, vaccines, and technologies, and health financing to enhance CC response [55–57]. It is important that CC funds are ring-fenced in national budgets for health systems to aid prompt response.

This scoping review has revealed some evidence gaps for the effective implementation of the strategies and responses. Gaps in funding, insufficient knowledge among health workers on CC and health, and inadequate surveillance systems are some of the challenges faced. Overall, the identified gaps may hinder the ability of the health systems to timely recover from CC-related stresses and shocks. Similar findings were also reported in another scoping review on climate change and health systems [58]. Interestingly, another study reported on the need to intensify green climate change insurance, and strengthen current bilateral and multilateral programmes as an alternative way to enhance CC funding [59]. Apparently, health workers are increasingly aware of the rising CC-health risks but require formal training and better infrastructure that can overcome CC stresses [60]. The current review has an implication to prompt future research to explore the capacity of the health systems to conduct CC vulnerable assessments. Furthermore, this review may prompt future studies to understand mechanisms that can improve the CC health financing system, health system resilience, and surveillance systems.

Limitations

This scoping review has some limitations. The findings presented here have not captured the global health system’s CC strategies and responses, which limits the generalizability of the findings. Another notable limitation is the exclusion of book chapters and grey literature publications (dissertations, conference proceedings, abstracts, and reports), which primarily focus on CC strategies and responses without effects on health systems, which limits the comprehensiveness and depth of the identified evidence. This is so because the primary focus of this study was to map the strategies and responses aimed at strengthening the health system to the effects of CC. However, these limitations were addressed through a comprehensive search of articles that covered a period of more than a decade.

Conclusion

This scoping review has identified some health system strategies and responses to the effects of CC within the SSA region. The review has revealed that existing strategies and responses are fragmented and hindered by some implementation challenges, such as insufficient funding, lack of human resource capacity, and inadequate surveillance systems. The findings further provide a wider opportunity for policy consideration and formulation of guidelines that can strengthen health systems to respond to CC extreme weather events effectively. As CC continues to pose health threats to global health, urgent and effective interventions are required to minimize its impacts. It is essential to understand the unique vulnerabilities of the health systems, particularly those in the SSA region. The identified strategies and responses are essential for ensuring that health systems continue to provide healthcare services in times of extreme weather events. This calls for more comprehensive, integrated, and well-funded strategies across all six WHO building blocks for health systems (crucial for policymakers and researchers) to strengthen CC response within the SSA region. The time is now to develop strategies and responses that can improve and strengthen health systems as they protect population health against CC risks globally.

Supporting information