Health systems and environmental sustainability: updating frameworks for a new era
BMJ 2024; 385 doi: https://doi.org/10.1136/bmj-2023-076957 (Published 30 April 2024) Cite this as: BMJ 2024;385:e076957
- Michael Padget, researcher1,
- Michael A Peters, health specialist2,
- Matthias Brunn, affiliated researcher3,
- Dionne Kringos, associate professor4 5,
- Margaret E Kruk, professor of health systems6
- 1Massachusetts General Hospital Center for the Environment and Health, Boston, MA, USA
- 2Exemplars in Global Health, Gates Ventures, Seattle, USA
- 3Laboratory for Interdisciplinary Evaluation of Public Policies (LIEPP), Sciences Po, Paris, France
- 4Department of Public and Occupational Health, University of Amsterdam, Amsterdam, Netherlands
- 5Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- 6Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
- Correspondence to: M Padget mpadget{at}mgh.harvard.edu
Healthcare systems around the world have a responsibility to “do no harm” but are responsible for substantial negative health effects through the production of greenhouse gases, particulate matter, pharmaceutical waste, and other environmental pollutants.1 Recent studies estimate that the healthcare sector accounts for 4.6% of global greenhouse gases, and over 8% of these emissions in some countries.23 Although high income countries produce most health system pollution, low and middle income countries also contribute through poor hazardous waste disposal practices and other carbon intensive healthcare activities.45
Growing numbers of health systems have recognised the importance of their environmental impact and are acting to reduce it. To date, 82 countries, nearly half of which are classified as low or lower middle income by the World Bank, have signed an international pledge to develop climate resilient and low carbon health systems.6 In early 2023, over 100 health systems in the US signed a health sector climate pledge endorsed by the White House to achieve net zero emissions by 2050.7 Health systems in the UK and many other European countries have also developed extensive decarbonisation plans.89
Despite these multiplying pledges and the urgency to act, real progress has been uneven. Simple and important actions, such as substituting highly polluting anaesthetic gases for equally effective, less polluting options, have not been universally adopted.10 In clinical practice, heavy reliance on disposable devices persists even when moving to a reusable option is safe, less costly, and less polluting.11 Education on the inter-relatedness of climate and health and the importance of health system sustainability remains rare in medical schools.12
A major barrier to progress on environmental sustainability is the perception among some key stakeholders such as healthcare purchasers, managers, staff, and providers that environmental sustainability goals do not belong among fundamental health system priorities. In 2023, the Joint Commission, the largest and most important hospital accreditation organisation in the US, decided to make its environmental sustainability metrics optional after hospitals and health systems argued that the topic was not relevant when dealing with more urgent issues.13 Health systems often consider environmental sustainability a “nice to have” that is combined with other social responsibility goals, or is encouraged only if it can be linked to cost savings.14 Environmental topics may also be considered to be political or belonging to the realm of activism by healthcare workers.15 This perception has hindered the advancement of environmental sustainability efforts along with the development of crucial tools, data, and research.
To fulfil the health system’s purpose of promoting health and to accomplish stated goals, environmental sustainability must be accepted as a central mission of the health system by all those involved, including governments, funders, healthcare providers, academia, regulatory bodies, and patient groups. To support this, we suggest that environmental sustainability be adopted as a core responsibility of the health system in all countries and included in a revised definition and framework for high quality health systems.
Embedding sustainability in health system quality
Health system quality frameworks help to conceptualise, prioritise, and operationalise the function and goals of the health system. Several widely used frameworks exist, including the World Health Organization’s (WHO) building blocks framework, which focuses on ensuring quality through adequate financing, workforce, information systems, medical products and technologies, leadership and governance, and service delivery.16 This framework has been incorporated into common health system evaluation tools and influenced work worldwide on indicator development, reporting, research, and other system components. Another widely used framework was developed by Institute of Medicine (IOM), which focuses on delivering safe, effective, patient centred, timely, efficient, and equitable care.17 Patient safety initiatives, which today represent a central focus of quality improvement efforts and measurement, were popularised in part by the inclusion of safety in the framework in 1999.
The framework for high quality health systems produced by the Lancet Global Health Commission on High Quality Health Systems in 2018 builds on the WHO, IOM, and other frameworks by focusing on system foundations, processes, and impacts.18 All system components are guided by the principles of efficiency, resilience, equity, and people centredness. This holistic focus makes this framework useful for tackling the rising challenges of chronic and complex conditions.192021 The framework has also been incorporated into health services research in low and middle income countries and shaped discussions of care quality in WHO documents supporting improved primary care and maternal, newborn, and child health.222324
To achieve ambitious health systems goals and overcome current hurdles, environmental sustainability will need the support of quality frameworks and the corresponding quality infrastructure. Treating environmental sustainability as a health system quality issue would increase awareness and prioritisation of the topic; help to embed it into decision making across multiple levels; promote engagement and support from existing organisations involved in creating and maintaining quality standards such as healthcare inspectorates, funders, medical associations, and patient organisations; and stimulate progress on key topics such as the supply chain, care coordination, and prescribing.25 Importantly, it would also provide a conceptual structure to facilitate discussions about how environmental sustainability relates to other system goals and priorities, particularly in cases where they are not aligned.
Adapting health system quality frameworks
The structure and multifaceted approach of the Lancet commission’s high quality health system framework make it well suited for the integration of environmental sustainability, which must be integrated into multiple components of the health system to be effective. In this framework, environmental sustainability would fit as a fifth overarching principle used to help guide the foundations, processes, and outcomes of care (fig 1). Table 1 provides examples of how environmental sustainability can be linked conceptually or operationally to the components of this framework.
High quality health system framework including environmental sustainability as an overarching principle
Examples of environmental sustainability links or work within each component of a high quality health system18
Applying an adapted high quality health system framework means that environmental sustainability should be considered across all health system components, from system planning to clinical care. Because sustainability is considered alongside other principles, actions may differ depending on the context. For example, in its guidance for climate resilient and environmentally sustainable healthcare facilities, WHO recommends assembling and training a multisectoral operative team, establishing a baseline, defining and prioritising short term and long term interventions, developing and implementing an improvement plan, and monitoring and evaluating improvements.26 Each of these steps requires time and resources. In a health system with few resources that has not achieved sufficient equity or resilience but has a low environmental footprint, the relative benefit of investing in this strategy may be limited. In a higher resource setting where the system creates more pollution and has achieved greater overall performance, this approach may be more valuable. This does not mean that environmental sustainability is irrelevant in low resource settings since many examples exist of less polluting care or system options in these contexts that can also support patient care or other priorities.527
Examples of environmental sustainability aligning with existing principles include reducing unnecessary care, which supports the principle of efficiency; use of telemedicine, which can support patient access and equity; and investment in primary care and public health, which may help avoid high resource care and improve health outcomes. In other cases, environmental sustainability may align with one principle but not another or be in direct conflict with other principles—for example, if a less polluting option increases costs. An adapted framework can help identify and highlight these examples.
Expanding the definition of health system quality to include environmental sustainability would also expand the role of existing organisations that measure quality, accredit and certify healthcare organisations, and provide education or conduct research on quality topics. Examples of this work may include the creation and reporting of new quality measures focused on environmental sustainability, education on environment and health topics as part of quality training and assessment, or inclusion of environmental effects into health technology assessments or other decision aids. Some of these efforts are already underway (box 1), and frameworks can help organise, highlight, and expand these efforts. While many of the structures involved in quality would remain the same, participation and expertise from sectors not typically considered in quality such as building management, environmental services, purchasing, and others would be needed.
Current environmental sustainability efforts
Environmental sustainability in healthcare has been advancing quickly in the UK, where work and research are underway on purchasing criteria and supply chain, low carbon patient pathways and medicines, and specific specialty recommendations.2829 Notably, the Care Quality Commission in England, which ensures the quality of health provision through regular inspections and monitoring, has recently added environmental sustainability to its list of quality evaluation criteria30
Internationally, WHO has published guidance on creating climate resilient and environmentally sustainable healthcare facilities, calling for comprehensive action across the health systems building blocks.2631 Although this guidance is structured on the WHO building blocks framework, environmental sustainability is not included in the actual framework
Aga Khan Health Services has been a pioneer in calculating carbon emissions, waste generation, and water use for its facilities, located in eight low and middle income countries. It has developed a carbon management tool with WHO, which it uses to implement activities to reduce carbon emissions in facility construction, operation, and service delivery32
The SusQI approach developed by the Centre for Sustainable Healthcare in the UK provides a model for the integration of environmental sustainability into quality assessment, and its use has contributed to the expansion of sustainability work in the NHS33
Action is needed now
Redefining models of quality and integrating them into health systems requires time and resources. Adding additional responsibilities to already overburdened healthcare staff and systems when they are recovering from the covid pandemic may not be ideal. Organisations involved in assessing and validating quality may also find this expansion of responsibilities difficult given the necessity for new expertise. However, health must remain a priority, even if this requires new concepts and practices at an inopportune time. Conversely, this period may present an opportunity for change as health systems are already considering fundamental questions of design and resilience.34
Some may question the effectiveness of leveraging quality frameworks to advance environmental sustainability, particularly when other performance improvement efforts have stalled or led to unintended consequences, such as an excessive focus on measurement affecting patient care or increased costs.3536 Although the quality improvement movement may not have achieved all desired outcomes, it has been successful in increasing awareness, stimulating research, influencing policy, and encouraging investment and work on the topic. These same steps are desirable and necessary to achieve environmental sustainability in healthcare.
The actions and expertise needed to support environmental sustainability can also alleviate some of the unintended risks of quality work. Many effective actions to reduce the environmental impact of healthcare, such as capital investments or work with the supply chain, take place outside the realm of patient care; these can be cost saving and may be more straightforward to implement than many of the systematic or behaviour changes necessary for achieving traditional quality objectives such as reduced patient harm. Environmental goals that require behaviour change, such as reducing low value care, would probably face many of the same challenges as those of other quality improvement interventions and would require specific efforts to overcome them.
The speed and practicality of using quality frameworks might also be questioned. If decarbonisation is urgent, why should we spend time discussing concepts rather than acting? Including environmental sustainability in quality frameworks does not preclude action and has the potential to accelerate and expand ongoing efforts by providing a stronger conceptual foundation and basis for acting. Achieving environmental sustainability will take time and considerable effort. Creating a solid conceptual foundation capable of integrating multiple interests may ultimately lead to more consistent and streamlined decision making. Lastly, environmental sustainability has no expiration date and must remain a health system priority beyond specific target dates. Careful consideration of this topic today will ensure it is included in decision making now and into the future.
Our proposed framework adaptation focuses on environmental sustainability whereas WHO and others propose an approach combining both environmental sustainability and climate resilience.31 However, the high quality health system framework’s existing principle of resilience includes the ability to adapt to changing contexts, including climate change. This same logic may not be applicable to other quality frameworks.
Forging consensus on sustainable health systems
Changing quality frameworks means first creating a consensus around these changes. The participation of organisations that define and diffuse healthcare quality such as the National Academy of Medicine, WHO, or the Organization for Economic Cooperation and Development is critical to the incorporation of environmental sustainability into these frameworks. Other groups such as the Lancet Commission on Sustainable Healthcare, the Centre for Sustainable Healthcare in the UK, or the Nordic Centre for Sustainable Healthcare can also support this approach.
This conceptual work is an important step in shaping opinions on environmental sustainability and providing a way forward, but it is far from the last step. Implementing the necessary changes requires action at all levels, including health providers, academics, administrators, patient groups, governmental bodies, and funding organisations. Importantly, progress will require collaboration with groups not typically considered as being within the medical sphere. Data will also be needed to support environmentally informed decision making and track progress. Resources such as the HealthcareLCA database or support from the Agency for Healthcare Research and Quality on measuring sustainability provide examples to be further developed.3738
Despite the considerable effort ahead, this work is urgent and necessary. Incorporating environmentally sustainability into health system frameworks is an important part of this critical journey.
Key messages
Environmental pollution from health systems contributes to large negative health effects
Progress on pledges to reduce pollution in the health sector has been slow because the topic is often seen as outside core health system responsibilities
Placing environmental sustainability as a core concept in health system quality frameworks can help support efforts to reduce health system pollution
The high quality health system framework provides an effective illustration of how environmental sustainability can be integrated into quality frameworks
Acknowledgments
This article has received support from the French National Research Agency (ANR) Investissement d’avenir programme as part of the IdEx Université Paris Cité (ANR-18-IDEX-0001).
Footnotes
Contributors and sources: MP is a health policy analyst and researcher with expertise in health system quality measurement and environmental sustainability in health systems. MAP is a health systems and policy researcher who works on multisectoral efforts to improve quality in health systems in low and middle income countries. MB is a researcher on comparative health policies and politics in Europe and works with MP on integrating environmental sustainability into health system decision making. DK and MEK are internationally recognised experts and researchers on health system quality. MP and MEK conceived the article. MP drafted the manuscript. All authors revised the manuscript critically for important intellectual content and approved the final version.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that MEK was chair of the Lancet commission that produced the high quality health system framework.
Provenance and peer review: Not commissioned; externally peer reviewed.