Towards climate resilient health systems: implementation of climate adaptations for health in Western Cape, South Africa

As global climate change accelerates, its impact on human health and health systems grows. For the health system to protect communities and effectively respond to climaterelated shocks and stressors, it must prioritize climate adaptation and resilience. Although global commitments to climate resilient and sustainable health systems have grown in recent years, their implementation remains understudied. It is therefore crucial to assess how climate adaptations for health are implemented across governance levels and sectors by examining how decision-makers manage climate risks, such as heat and drought, at the subnational level. South Africa, vulnerable to rising temperatures, has emphasized health as a priority adaptation sector in climate policy since 2011. The Western Cape province is affected by climate hazards, experiencing a severe drought from 2015-2018, extreme heat events and wildfires. Through a policy document analysis and in-depth interviews, this thesis investigates the factors influencing the implementation of climate adaptations for health at the subnational level through a case study of the Western Cape. The results are shown through three interconnected research papers. First, a comprehensive policy document analysis assesses the coherence of climate, environment, and health policies at national and provincial levels. The findings reveal minimal coherence at the national level and none at the provincial level, except for some coherence around health adaptation to heat. The second paper highlights the Western Cape health sector’s key role in the 2017/18 drought response, emphasizing the importance of health system software factors in managing climate shocks. These findings offer critical insights for strengthening health systems against future droughts and is a significant contribution to the literature on the western cape drought. Finally, the third research paper examines the governance of heat-related health risks, revealing that despite a national heat health policy, action on managing heat-related health risks remain limited. The findings suggest that Western Cape provincial and municipal stakeholders were excluded from policy development, while weak cross-sector coordination, unclear departmental responsibilities, difficulties in localizing interventions, and varying perceptions of heat risk hinder effective governance of heat-related health risks. Collectively, the research studies in this thesis demonstrate the need for inclusive and context-specific adaptation actions, as well as cross sectoral governance structures to implement climate adaptation policies for health. The Western Cape experience highlights that effectively managing climate-related health risks, like drought and heat, depends on organizational and individual capacities for coordinated action, rather than relying on policy documents. The interplay between individual capacities, such as values, knowledge, and relationships and organizational capacities, such as leadership, is central to effective climate adaptation in health systems. Policies should include these capacities that foster adaptive capacities and institutionalize continuous learning, ensuring health systems can remain responsive and can transform as climate risks evolve