{"paper_id":"0c7fab96-aaeb-4116-a7cf-458056ff0fd5","body_text":"Health systems’ responses to climate change: an umbrella review of systematic reviews | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Health systems’ responses to climate change: an umbrella review of systematic reviews Katarzyna Dubas-Jakóbczyk, Magdalena Mrożek-Gąsiorowska, Costase Ndayishimiye, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9095097/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Climate change places increasing pressure on health systems. They must both reduce their negative impact on the environment and strengthen resilience to climate-related risks. Objective To synthesize and map the evidence from systematic reviews on the scope and effectiveness of climate change mitigation and adaptation actions in health systems. Methods An umbrella review of systematic reviews examining health system responses to climate change was conducted. The review followed the Joanna Briggs Institute methodological guidelines and adhered to the PRISMA checklist. The included systematic reviews had to meet two overarching criteria: at least two databases were searched, and a predefined instrument was used to assess the quality or risk of bias of the included studies. Results Thirty-nine systematic reviews published between 2020 and 2025 were included, covering 933 individual studies. Most reviews (35/39) focused exclusively on mitigation strategies, with evidence concentrated around major greenhouse gas emission hotspots: surgical procedures; radiology; pharmaceuticals; food waste; and transportation of patients and staff. Across these areas, many mitigation strategies were associated with environmental and economic co-benefits, although the underlying evidence was heterogeneous and often of low to moderate quality. In contrast, only a small number of reviews addressed climate adaptation and health system resilience. Conclusions Existing evidence provides practical guidance on effective climate mitigation actions. The limited number of systematic reviews on climate adaptation highlights a gap in the evidence base. Translating mitigation evidence into clinical guidelines and policies and strengthening research on adaptation could support more systematic climate action in health systems. Health Policy Climatology Health Economics and Outcomes Research Environmental Policy climate change health system environmental sustainability climate resilience climate mitigation climate adaptation Figures Figure 1 Figure 2 1. BACKGROUND Climate change is the most significant threat to human health globally 1 – 3 . It negatively affects population access to basic human needs, such as clean air and water, increases the burden of climate-related risk factors and diseases, and alters patterns of disease transmission 3 , 4 . At the same time, the increasing frequency of extreme weather events (e.g., floods, hurricanes) disrupts health care delivery 3 . Consequently, climate change impacts health systems by simultaneously increasing the demand for healthcare provision and impairing their ability to respond. Current prognoses predict that more severe climate risks will emerge sooner than previously expected 5 , putting an enormous pressure on health systems to implement adequate response strategies 6 . The health system response to climate change comprise two closely interdependent dimensions: 1) environmental sustainability, which aims at mitigating the negative impact of health systems on the environment by reducing its greenhouse gas (GHG) emissions, and 2) climate resilience, focusing on adaptations measures to better cope with the impact of climate-related shocks and stress 7 . Within both dimensions, a variety of actions can be implemented at different levels of the health system, and their effectiveness can be assessed using diverse direct and indirect metrics (Table 1 ). The World Health Organization’s (WHO) “Operational framework for building climate resilient and low carbon health systems” integrates both concepts into guidance on health system transformation 7 . Table 1 Conceptual framework of health system’s response to climate change Dimension Health system’s response to climate change Environmental sustainability - MITIGATION Climate resilience – ADAPTATION Focus reducing the negative impact of health systems on environment better coping with the impact of climate change Examples of actions • changes in clinical practice to reduce greenhouse gas emission, • reducing low-value care, • investments in renewable energy sources, • more sustainable waste management, • reducing health workforce travel, • incorporating sustainability rules into procurement contracts • implementing early warning systems, • planning back-up systems for service delivery during climate-induced disasters, • investing in climate-proofing of health infrastructure, • training the health workforce in disaster management Examples of effectiveness measures • reduction of greenhouse gas emissions (e.g. in kilograms (kg) per year or per specific health care service/product life cycle) • reductions in plastic waste or water usage per patient/procedure • reduction in the number of deaths or people affected by climate-related disasters per 100,000 population, • reduction in heat-related excess mortality • reduction in frequency of healthcare provision disruption/infrastructure damage due to climate-related disasters Source: Authors’ own compilation Health system responses to climate change have emerged as an important priority for health policy and research 8 . Under the auspices of the WHO, The Alliance for Transformative Action on Climate and Health has brought together over 100 countries whose Ministers of Health have committed to strengthening the climate resilience of health systems and/or reducing their GHG emissions 9 , 10 . Research on health system response to climate change has expanded significantly, with numerous reviews published in the last two years (2024–2025), including systematic 11 – 16 , rapid 17 , 18 , scoping 19 – 22 , integrative 23 , 24 and/or narrative 25 , 26 reviews. However, important gaps remain: Many systematic reviews focus only on a narrow aspect – for example environmental sustainability in a chosen medical discipline 11 , 16 or adaptation to heat related risks 15 . In contrast, rapid, scoping and narrative reviews typically cover a broader range of actions but they do not conduct quality and/or risk of bias assessments of the underlying evidence. For evidence-informed health policy, however, the quality of the research evidence is crucial. To address these limitations, we conducted an umbrella review of systematic reviews on environmental sustainability and climate resilience actions in health systems, focusing on reviews that included a quality and/or risk of bias assessment of their underlying primary studies. Umbrella review are particularly valuable when several recent and still up-to-date systematic reviews on the topic are available 27 . Our main goal was to offer decision makers a comprehensive and policy-relevant overview of the available evidence on environmental sustainability and climate resilience actions 28 , 29 . More specifically, the objectives were to: 1) characterize the main features of existing systematic reviews; 2) map the scope of available evidence on health system responses to climate change by geography, health system level, and type of response; and 3) synthesize evidence on the effectiveness of specific response strategies. 2. METHODS The work followed the Joanna Briggs Institute (JBI) methodological guidelines for evidence synthesis in umbrella reviews 28 , 29 and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 30 . The review was registered in PROSPERO (CRD420251052647) 31 , while its protocol was published in a peer-reviewed journal 32 . 2.1. Review questions Three specific review questions were defined: 1) What are the main characteristics of the published systematic reviews?; 2) What is the scope of the available evidence on health system response to climate change (by geography, health system level, and type of response)?; 3) What evidence exists regarding the effectiveness of particular response strategies? 2.2. Inclusion and exclusion criteria We defined inclusion and exclusion criteria using the PICOS (Population, Intervention, Comparison, Outcomes, Study design) framework 33 (see Table 2 ). Broadly speaking, we included systematic reviews that examined health system responses to climate change, focusing on environmental sustainability and/or climate resilience. For both concepts, we applied the WHO definitions 1 . In addition, systematic review had to meet the following quality criteria: 1) at least two databases were searched, and 2) a predefined instrument was used to assess the quality or risk of bias of the included studies. Table 2 Inclusion and exclusion criteria Element Inclusion Exclusion P - Population Health system stakeholders at macro, mezzo, and micro levels (e.g. systematic reviews focusing on health systems as a whole or their subsectors e.g. hospital providers, general practice) Studies with a primary focus outside the health system stakeholders (e.g., urban planning, agriculture) I - Intervention Health system response to climate change, captured within: I - environmental sustainability (e.g., actions aimed at reducing greenhouse gas emissions), and/or II - climate resilience (e.g. actions aimed at improving preparedness for climate-induced disasters), using WHO definitions Studies focusing on the impact of the climate crisis on population health or changing disease patterns, changes in risk factors, changes in healthcare demand (e.g., increased hospital admissions). Studies that measure the impact of HS on environment (without offering solutions on how to limit the negative impact or without comparing which solution is less harmful for the environment). Studies addressing health system preparedness for non-climate-related disasters (e.g. terrorist attacks) C - Comparison Not applicable Not applicable O - Outcome Outcomes of response strategies, including: I – environmental sustainability measures (e.g., decreased carbon footprint measured in CO2e kg/year or reduced plastic waste in kg) and or II - climate resilience measures (e.g. health facility safety index, or chosen population/ health system-level indicators of climate resilience as defined by WHO) Studies that focus on attitudes, barriers and facilitators to the health system response to climate change without the analysis of strategies outcomes/effectiveness (e.g., reviews focused on medical professional education, curricula content) S – Study design/type Systematic reviews (or other types of reviews) that report on the quality/risk of bias assessment of the included studies Must be published in a peer-reviewed journal. Any types of systematic literature reviews where quality assessment/risk of bias of the included studies was not conducted. Systematic reviews not published in peer-reviewed journals. 2.3. Search strategy In July 2025, five databases were searched: 1) MEDLINE via PubMed, 2) Scopus, 3) Web of Science Core Collection, 4) ProQuest Central, and 5) Cochrane Database of Systematic Reviews. The search strategy was developed in accordance with the PRESS guidelines 34 and combined multiple terms related to climate change AND health system AND systematic review. Where available, a dedicated filter for systematic reviews was applied. Terms were searched as keywords in the title and/or abstract fields, and, when appropriate, Medical Subject Headings (MeSH) terms were also used. Prior to finalization, the strategy was tested across all five databases to ensure accuracy and relevance. We included studies published from 2015 onward, with full text available in English. Table S1 Supplementary File presents the full search strings for each database. In addition, the references of included studies were screened to identify additional systematic reviews that met the inclusion criteria. 2.4. Selection of studies All records were downloaded and deduplicated using Rayyan software 35 , which also supported the study selection process. This process involved two stages: 1) screening of titles and abstracts and 2) full-text assessment. Two researchers independently participated in both stages and evaluated the records/full texts according to the predefined inclusion and exclusion criteria (Table 2 ). Any discrepancies were resolved through consensus between the two researchers. 2.5. Quality appraisal The JBI critical appraisal checklist for systematic reviews and research syntheses 28 , 29 was used to assess the quality of included reviews. This tool, applicable to both quantitative and qualitative studies, contains eleven items rated as ‘yes’, ‘no’, ‘unclear’, or ‘not applicable’. A scoring guide specific to this umbrella review was developed, with ‘yes’ scored as 1.0, ‘unclear’ as 0.5, and ‘no’ as 0.0. Reviews scoring above 75% were considered high quality, 50–75% moderate, and below 50% low quality. Table S2 in Supplementary File presents details of the appraisal matrix. Two researchers independently conducted the assessments and resolved discrepancies through consensus. 2.6. Data extraction The data extraction table was developed in an MS Excel file following JBI recommendations for umbrella reviews 28 . It was pilot-tested on five included studies and revised as needed. The table included the following main sections: citation details; review questions; number of databases searched; date range of included studies; characteristics of included studies; quality appraisal; evidence certainty assessment; scope of climate action strategies; effectiveness of strategies; policy recommendations; additional notes. Two researchers independently extracted data, compared results, and resolved discrepancies through discussion. In the case of missing data the corresponding authors of included reviews were contacted with the request to provide relevant data. 2.7. Data synthesis Data were summarized using both quantitative and qualitative methods. Thematic analysis (both inductive and deductive) was used to summarize and map the identified mitigation and adaptation strategies. To identify the scope of overlapping publications (primary studies) across included systematic reviews the corrected covered area (CCA) was calculated following the Pieper at al. 36 method. The results of the quality appraisal of included systematic reviews, together with extracted data on evidence certainty (where available), were taken into consideration while drawing final conclusions and formulating policy recommendations 37 . 3. RESULTS 3.1. Search results The search across the five scientific databases identified 4,433 records. After removing duplicates, 2,713 records were screened based on titles and abstracts, leading to 191 articles selected for full-text review. Of these, 37 publications met the inclusion criteria. The most common reason for exclusion was an inappropriate study design, usually related to the absence of quality appraisal of included studies in scoping reviews, or an unsuitable publication type – usually narrative reviews, where search results were not summarized (Fig. 1 ). Table S3 Supplementary File provides the full list of excluded studies along with the reasons for their exclusion. Two additional reviews were identified through reference list screening, resulting in a total of 39 included reviews (37 systematic reviews, one scoping review, and one integrative review—all meeting the criteria for study quality appraisal and reporting) (Table S4 in Supplementary File). 3.2. General overview of the included reviews Table 3 presents a general overview of the included reviews. All 39 were published within the last five years (2020–2025). The vast majority (35/39) focused on environmental sustainability. Three reviews addressed climate adaptation actions, while one included primary studies examining both mitigation and adaptation strategies at the hospital level (Fig. 2 ). The number of primary studies included in the reviews ranged from 8 to 205, while the total number of studies across all 39 reviews was 1,161 (933 after eliminating overlapping ones). The majority of reviews (21/39) included relatively new research (published since 2010) and applied language limitation to studies published solely in English (25/39). With the exemption of one 38 , all reviews included studies conducted either exclusively (23/39) or predominantly in high-income countries (15/39) (Table 3 ). The overall corrected covered area (CCA) ratio is 0.64%, (0.77% and 0.28% in the mitigation and adaptation groups, respectively) indicating only slight overlap of primary studies across the included reviews. *colours: green – environmental sustainability (mitigation); orange – climate resilience (adaptation); grey – both mitigation and adaptation; the box’s size corresponds to the number of primary studies included in the reviews (n = 1161 across all 39R) Table 3 General overview of the included systematic reviews (chronological order) No 1st author and ref. no Publication year Dimension* Review’s topic No of incl. stud. Country of origin of incl. stud. (high- vs, middle, vs low-income countries) The date range of incl. studies Quality assessment result 1 Carino 39 2020 M food waste in hospitals (across supply chain) 80 Mixed, mostly high-income, with the highest no. of studies from: US (19), UK (8), Denmark (8), Australia (5) 1945–2018 high 2 Rizan 40 2020 M surgical operations (mix) 8 Mixed, mostly high-income: US (4), UK (2), Chile (1), India (1) 2011–2018 moderate 3 Mashallahi 41 2022 M, A mix - hospitals mitigations and adaptation 26 Mixed, mostly high-income, with the highest no. of studies from: US (5), Australia (4), UK (4) 2009–2020 high 4 Mohtady Ali 42 2022 A hospital disaster preparedness 22 Mixed, high-, middle and low-income countries. The highest no of studies from: US (4), Australia (3), China (3), UK (2), Sierra Leone (2) 2006–2021 high 5 Papadopoulou 43 2022 M surgical operations - minimally invasive surgery 16 Mixed, mostly high-income: US (9), Japan (2) + 1 from Germany, Canada, France, India 2005–2021 moderate 6 Anudjo 44 2023 M radiology (mix) 14 High income: US (5), The Netherlands (2), Switzerland (2) + 1 from UK, Germany, Ireland, Canada, Australia 2015–2023 high 7 Batcup 45 2023 M mix - behavioural change interventions (in clinical settings) 20 High income: UK (15), US (3), Australia (2) 2016–2021 high 8 Cook 46 2023 M food waste in hospitals 85 Mixed, mostly high-income, with the highest no. of studies from: US (37), Australia (15); Canada (9), UK (9) 2002–2020 high 9 Keil 47 2023 M single-use vs reusable healthcare products (mostly within surgical operations) 27 High income with the highest no of studies from: US (11), Australia (5), Germany (2), The Netherlands (2) 2008–2022 moderate 10 Lam 48 2023 M surgical operations (mix) 21 High income with the highest no of studies from: US (11), UK (7), Australia (5) 2012–2022 moderate 11 Perry 49 2023 M surgical operations (mix) 34 High income with the highest no of studies from: US (18), Australia (6), UK (5) 1994–2018 high 12 Pickard Strange 50 2023 M telemedicine 23 High income, with the highest no of studies from: UK (8), US (7), Spain (2) 1996–2021 high 13 Rodler 51 2023 M telemedicine 48 High income with the highest no of studies from: US (20); UK (12); Australia (5); Canada (3) 2013–2023 high 14 Wicklum 52 2023 M PHC - decarbonisation toolkits (mix) 20 Mixed, mostly high-income, with the highest no. of studies from: US (8), UK (7), Canada (4) 2007–2022 moderate 15 Blom 38 2024 M mix - different strategies / health system levels 22 Middle income, with the highest no of studies from India (6), China (3), Malaysia (2), Pakistan (2) 2000–2022 high 16 Braithwaite 2024 53 2024 M mix - different strategies / health system levels 205 Mixed, mostly high income, with the highest no of studies from: US (27), UK (21), Australia (17), and Canada (14). 2005–2023 high 17 Chauvet 54 2024 M surgical operations - single vs multiuse laparoscopic instruments 14 High income: US (4), UK (3) + 1 from Australia, Canada, Belgium, France, Germany, Greece, Switzerland 1994–2022 moderate 18 Cohen 16 2024 M surgical operations – obstetrics and gynaecology (mix) 17 Mixed, mostly high income: US (11), Canada (2), UK (1), Netherlands (1), multi-country (2) 2004–2022 moderate 29 Davies 12 2024 M surgical operations (mix) 11 High income: US (8), Canada (2), multi-country (1) 2010–2021 moderate 20 Eussen 55 2024 M surgical operations - single vs multiuse instruments 53 Mixed, mostly high-income, with the highest no. of studies from: US (15), Germany (10), UK (7) 1991–2023 moderate 21 Gumera 56 2024 M surgical operations - single vs multiuse headwear 9 High income: US (8), the Netherlands (1) 2017–2022 high 22 Kloevekorn 13 2024 M surgical operations (mix) 18 High income: US (6), UK (3), Australia (2), Canada (2) + 1 from Turkey, France, Spain, Denmark, Ireland 2018–2024 moderate 23 Martins 57 2024 M surgical operations - single vs multiuse instruments in minimally invasive procedures 13 High-income: Denmark (3), US (3), Australia (2) + 1 from France, Ireland, Sweden, UK, Germany 2005–2023 high 24 Nolan 58 2024 M surgical operations - behavioural interventions on anaesthetic agents 13 High income: UK (9), US (2) + 1 from Australia, New Zealand 2011–2022 high 25 Pickles 59 2024 M mix - different strategies / health system levels 21 High income, with the highest no of studies from: US (7), UK (6), Australia (3) 2011–2023 high 26 Roletto 60 2024 M radiology (mix) 16 High income: US (7), Switzerland (3), UK (2), + 1 from Ireland, Canada, Australia, Germany 2010–2023 moderate 27 van der Zee 61 2024 M telemedicine 28 High income with the highest no of studies from: UK (10); US (10); Australia (2) 2010–2022 moderate 28 Vu 62 2024 M surgical operations (mix) 13 High income: US (7), Canada (3), France (2), Portugal (1) 2010–2023 moderate 39 Cunha 63 2025 M surgical operations - abdominal surgery 8 High income: US (5), UK (2), Italy (1) 2008–2023 moderate 30 Iakovou 64 2025 M surgical operations - plastic surgery 15 High income: US (10), UK (3), Chile (1), Switzerland (1) 2017–2023 high 31 Johar 15 2025 A community-based heat adaptation 10 Mixed, mostly high income: Australia (2), Japan (2), China (2) + 1 from US, Canada, Italy, Pakistan 2000–2023 high 32 Hammer 65 2025 M surgical operations - anaesthetic agents 13 High income: France (3), US (4), Germany (2), Switzerland (1), Singapore (1), South Korea (1), Australia (1) 2019–2024 moderate 33 Nunes 66 2025 M PHC – decarbonisation (mix) 15 High income: UK (5), Australia (3), US (2), Germany (2) + 1 from France, Switzerland, Israel 2016–2023 high 34 Onasanya 67 2025 M pharmaceuticals - inhalers 64 Mixed, mostly high income with the highest no of studies from UK (24) 2014–2024 high 35 Peyrottes 68 2025 M surgical operations - single vs multiuse instruments in urological endoscopic procedures 10 High income: Australia (3), France (3) + 1 from Canada, Ireland, UK, US 2018–2024 high 36 Pitard 69 2025 M pharmaceutical - hospital pharmacy (mix) 17 Mixed, mostly high-income: France (4), US (4), Ethiopia (2), Saudi Arabia (2) + 1 from England, Italy, Netherlands, Brazil, Spain. 2014–2022 high 37 Tozsin 11 2025 M surgical operations - single vs multiuse instrument in urological procedures 10 High income: France (3), US (2), Italy (2), Ireland (2), UK (1) 2018–2024 moderate 38 Zurynski 14 2024 A health workforce preparedness 60 Mixed, mostly high-income, with the highest no. of studies from: US (29), Australia (6) 2004–2023 high 39 van Nieuwenhuizen 70 2025 M surgical operations (mix) 42 High-income, with the highest no. of studies from: US (20), Australia (4), UK (3) 2012–2023 high *M - mitigation, A - adaptation 3.3. Quality of the evidence base More than half (23/39) of the included reviews were of high quality, while the remaining reviews were classified as being of moderate quality. Overall, the average quality score was 77%. The three most common quality problems were (1) lack of clearly and explicitly stated review question (28/39); (2) inclusion criteria not based on a dedicated framework (e.g., PICO) (22/39); and (3) searches conducted in fewer than five databases (23/39) (Table S2 in Supplementary File). In 23 reviews, a single instrument/checklist was used to assess the quality and/or risk of bias of the included primary studies, while in the remaining 16 reviews, between two and four different instruments were used (depending on the type of primary studies). In most reviews, the results of quality appraisal/risk of bias assessment of individual studies varied considerably. In only two reviews 44 , 60 , the pooled, overall quality score was above 80%, while in the vast majority of cases, the results were not pooled, only presented for each individual primary study and ranged from low or moderate to high quality/risk of bias. In two reviews 42 , 53 , studies of low quality were excluded from the data synthesis. In three reviews 38 , 59 , 70 , the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) 71 , 72 approach, and in all three cases the overall certainty of evidence was rated as low (Table S5 in Supplementary File). 3.4. Evidence on the scope and effectiveness of environmental sustainability actions The 36 reviews on mitigation strategies (including one addressing both mitigation and adaptation) focused on eight main themes (see Fig. 2 ). More than half concentrated on different types of surgical operations (20/36). Other themes included food waste, telemedicine, radiology, pharmaceuticals, primary health care, behavioural interventions, and mixed strategies at different health system levels, each addressed in in two or three reviews. The identified mitigation strategies can be clustered into five main dimensions based on Braithwaite at al. 53 , including: 1) optimizing energy use in buildings and equipment (e.g., switching to renewable energy sources, turning off the equipment when not in use); 2) changing clinical care to reduce environmental impact (e.g., moving away from anaesthetic gases with high global warming potential; choosing medical pathways with lower environmental impact; reducing low-value care, implementing water saving measures); 3) reducing waste and improving its management (e.g., replacing single-use medical instruments and protective materials by multi-use options; waste reduction, reuse and recycling; recovering energy from waste); 4) reducing travel and transport (e.g., telemedicine, scheduling consultation to minimize patient travel, remote professional cooperation); and 5) reducing supply chain emissions (e.g., through local and green procurement) (Table 4 ). Table 4 Reviews’ themes and mitigation actions dimension matrix Review’s theme / Mitigation dimension Optimizing energy use in buildings & equipment Changing clinical care to reduce impact on environment Reducing waste and improving its management Reducing travel and transport Reducing supply chain emissions Surgical operations: 20R, n = 365 ✓ ✓ ✓ Food waste: 2R, n = 165 ✓ ✓ ✓ Telemedicine: 3R, n = 99 ✓ Radiology: 2R, n = 30 ✓ ✓ ✓ ✓ Pharmaceuticals: 2R, n = 81 ✓ ✓ ✓ PHC: 2R, n = 35 ✓ ✓ ✓ ✓ ✓ Behavioural interventions: 1R, n = 20 ✓ ✓ Mix - different strat. /system levels: 4R, n = 274 ✓ ✓ ✓ ✓ ✓ Table 5 presents a general overview of the identified mitigation strategies (as classified in reviews) and the available evidence on their effectiveness. For the vast majority of identified strategies, the results clearly indicated a positive impact on the environment, manifested as reduced GHG emissions and/or reduced waste or water use. However, for two types of actions: 1) replacing single-use medical instruments (used mostly in surgical procedures) by reusable alternatives, and 2) selecting a surgical technique with lower emissions (mostly robot-assisted versus laparoscopic) – the evidence was mixed. While most high quality studies reported significant environmental advantages of reusable surgical instruments 40 , 48 , 57 , some studies suggested the opposite 11 or found no differences in carbon footprint between single and multiuse instruments 68 . Similarly, some studies indicated lower GHG emissions from robot-assisted surgeries compared to laparoscopic ones 11 , 63 , while others reported the opposite result 16 , 63 . Table 5 Synthesis of the identified mitigation actions and their effectiveness (36R) Review’s theme Strategy/Action Evidence on effectiveness* Impact on environment Surgical operations: 20R, n = 365 moving away from anaesthetic gases with high global warming potential (GWP) ✓ reduction of volatile anaesthetics, especially desflurane, lead to decrease in CO2e emissions between a 24% and a 98% 65 ✓ 12 out of 13 included studies reported reduced CO2e after application of educational interventions e.g., encouraging lowering fresh gas flow, applying intravenous anaesthesia 58 ✓ use of sevoflurane or propofol resulted in up to 60% reduced GHG emissions versus desflurane use 43 ✓ converting all suitable procedures from general to spinal anaesthesia can generate substantial CO2e savins 48 positive optimizing energy use in operating theatres (OR) ✓ turning off airflow systems during nights and weekends can save up to 70% of total energy use 70 ✓ installing occupancy sensors, low-energy lighting, energy efficient air-conditioning systems and water cooling systems showed significantly reduced carbon emission 40 ✓ turning off idle sterilizers reduced electricity by 26% and water use by 13% 49 ✓ installing occupancy sensors in the OR let do decreased CO2 emissions by 234.2 tons 48 positive replacing single-use medical instruments with multi-use options ✓ using reusable items showed a 70% waste reduction, 3 times lower water use, and 2.5 times lower energy consumption than disposables; disposable steel scissors had 99% higher environmental impact than reusable ones 40 ✓ hybrid devices in laparoscopic cholecystectomy emitted less CO2e than single-use devices (1.8 vs. 7.2kg) 63 ✓ 7 out of 8 studies showed lower environmental impact when using reusable endoscopic instruments 55 ✓ 3 high quality life cycle assessment studies (LCA) showed that multiuse instruments have a significantly lower (2–26 times) environmental footprint than their single-use counterparts in minimally invasive surgeries; several fair/poor quality studies favoured single-use 57 ✓ reusable equipment reduced CO2 emissions by 40–66% compared to single-use equivalents 48 ✓ single-use cystoscopes had lower emissions per procedure (2.4 kg) compared to their reusable counterparts (4.2 kg) but produced more waste; reusable cystoscopes, while having a lower cumulative waste per use, increased emissions due to energy-intensive reprocessing (the cumulative emissions results may depend on the sterilisation techniques and must be analysed by LCA) 11 ✓ in ureteroscopy, studies tend to show comparable carbon footprints for single-use and reusable instruments 68 ✓ minimal material and maximum reuse of equipment during hysterectomy resulted in 69% GHG emission reduction 43 mixed minimising waste produced by instruments packaging ✓ repackaging of disposable instruments into packs of essential items customized to laparoscopic gynaecological surgery at their institution, resulting in waste reduction of 400 g per case 43 ✓ using ‘green packs’ for ‘wide awake local anaesthesia no tourniquet’ cases showed a significant waste reduction (2.3 kg per case) 64 ✓ redesigning of hand surgery packs led to a 2.8 tonnes waste decrease 64 positive replacing single-use medical protective materials (e.g., headwear) by multi-use options ✓ reusable surgical head covers demonstrated a statistically significant lower carbon footprint, ozone depletion, fossil fuel depletion, terrestrial acidification, and fine particulate matter formation than disposable alternatives, while not impacting the surgical site infection rates 56 positive changing surgical techniques to those with lower environmental impact ✓ robot-assisted surgery had a higher environmental impact than laparoscopic and open surgery 70 ✓ 2 studies on hysterectomy showed that robotic surgery had the highest emissions (12.0–40.3 kg CO2e) compared to laparoscopic (10.7–29.2 kgCO2e) and open surgery (7.1–22.7 kgCO2e); 1 study showed that laparoscopic prostatectomy produced more emissions than robotic option (59.7 vs. 47.3 kgCO2e) due to higher disposable devices, longer surgery time and length of stay 63 ✓ robotic prostatectomy produced lower emissions than laparoscopic methods 11 ✓ using alcohol-based scrub limits water use (18.5 litres per person per scrub) 49 ✓ increasing the lifetime of multi-use devices and fully loading autoclaves for their sterilization further decrease their environmental impact 47 ✓ reducing custom pack contents and replacing single-use items reduced caesarean procedure footprint by 22% 16 mixed improving waste management ✓ increasing recycling resulted in a 2% reduction in greenhouse gas emissions 48 ✓ waste segregation/recycling and minimising unused supplies reduced emissions 13 ✓ installing paper and cardboard recycling bins in anaesthetic room and operating theatre increased recycling (up to 50%-67% waste) 49 ✓ educational campaign reduced infectious medical waste by 75% 48 positive Food waste: 2R, n = 165 choosing local suppliers/procurement ✓ using local food (direct 'farm to hospital' procurement), which limits transport, is most environmentally beneficial 39 positive using food ingredients and preparation techniques with lower environmental impact ✓ mediterranean-style diets and vegetarian menu generated lower GHG emissions and water use than the standard menu 39 ✓ using lean process tools reduced pre-service waste by 50%; fortified small portions decreases food waste by 5% 39 positive adopting consumption methods that minimize waste ✓ using bulk trolley instead of plating food in the kitchen; enabling patient choice (e.g., room-service model) and using porcelain plates instead of plastic trays reduced food waste by 8% 39 positive improving food waste management ✓ composting waste and donating surplus food substantially decreased total food waste volume 39 , 46 ✓ most strategies that avoid and/or reduce sending food waste to landfill (e.g., industrial use, feeding animals, worm farms) helped to limit GHG emissions positive Telemedicine: 3R, n = 99 implementing remote (telephone and video) consultations ✓ all studies across all three reviews showed that telemedicine reduces GHG emissions due to limited travel (though not all included primary studies calculated telemedicine emissions) 50 , 51 , 61 ✓ although limited, the studies where complete LCA of telemedicine solutions was performed also showed GHG emission reduction due to replacing face-to-face visit with remote options 51 positive Radiology: 2R, n = 30 optimizing energy use ✓ turning off workstations/devices after hours saved a substantial part of total energy 44 , 60 ✓ choosing energy efficient radiological equipment 44 positive reducing the use of consumables and radiopharmaceuticals ✓ limiting the use of diatrizoic acid (contrast agent) reduced environmental contaminations (e.g. in rivers) 44 positive reducing patients’ and staff travel ✓ investing in teleradiology/remote collaboration - online conferences (e.g., switching to online, the annual Radiological Society of North America conference can save 40 000 tons of CO2e due to travel) 44 positive Pharmaceuticals: 2R, n = 81 reducing pharmaceutical waste ✓ diversity of actions described as effective, including e.g.: educational interventions (for both patients and staff); providing information (audit and feedback on waste values; monthly bulletins of waste production); reminders to return unused medicines; changing dispensing/distribution practice (dosage on demand; increased frequency of batches preparation), incorporating of environmental sustainability rules into procurement contracts 67 , 69 positive switching to pharmaceuticals with lower carbon footprint ✓ switching inhalers from metered-dose (MDI) to dry powder inhalers (DPI) significantly lowered the carbon footprint while at the same time improved asthma control and adherence 67 positive PHC: 2R, n = 35 delivering PHC’s decarbonisation toolkits ✓ 11 toolkits were identified, all including educational materials for PHC staff, while 7 also included resources for patients; majority focused on clinical operations, procurement, energy use, and waste and recycling – although quantitative data were limited, the available evidence pointed towards a reduced environmental impact after toolkits implementation 73 positive implementing mix of actions, incl.: reuse of resources, improving waste management, revising prescriptions; saving energy; promoting telemedicine and health education ✓ no quantitative data were provided and the identified strategies’ results were not consistently reported; some strategies proved effective in reducing emissions (e.g., energy efficient solution; limiting patient travel by telemedicine and changes in appointment scheduling and prescription collection; social prescribing reduced further health care use, switching to dry powder inhalers reduced emissions) 74 positive Behavioural interventions: 1R, n = 20 implementing a mix of behaviour change techniques, incl.: change in policy/protocols, email updates, announcements, presentations, personalised and team feedback, reminder notes ✓ some strategies, especially comprehensive ones that applied more than one behavioural technique proved effective in reducing emissions, with most evidence focused on interventions that targeted anaesthesia and pathology test ordering in hospital settings, e.g., educational intervention on anaesthetic gases flow rate in perioperative settings showed 105 kg of CO2e reduction per case; behavioural intervention to reduce biochemical test ordering showed 10 tons of CO2e reduction per year 45 positive Mix - different strategies / health system levels: 4R, n = 274 changing clinical and surgical care pathways to reduce environmental impact ✓ interventions related to changing anaesthesia agent practices can lead to GHG reduction between 25% − 100% 59 ✓ targeting unnecessary resting (low-value care) limited emissions by 10%-37% 59 ✓ implementing multicomponent interventions to reduce low-value care (incl.: identifying and reducing unnecessary processes or procedures, minimising drug overprescription, encouraging a preventative care approach to reduce the need for health services) can successfully reduce emissions 53 ✓ implementing water use saving plans (e.g., automatic shut-off / low pressure valves, reporting water use to staff) can reduce water consumption 41 positive reducing waste volume and improving waste managements ✓ multicomponent waste reduction intervention incl. clinician education, audit and feedback, recycling, relocation of landfill, and converting from single-use to reusable sharps containers led to reducing GHG emission by 32%-85% 59 ✓ systems integrating waste segregation, composting and material recycling with simultaneous transport optimisation generated greatest emission reductions, ranging from 47%–114% 38 positive reducing travel and transport ✓ numerous studies examining different approaches to reduce travel and transportation (telemedicine, local care options, shared transport options, scheduling face-to-face appointment to minimize travel needs, reducing health professional’s business trips) showed positive results in terms on GHG emission reductions 53 positive optimizing energy use (in buildings and equipment) ✓ using a mixed energy sources or fully renewable once, led to CO2 emission reductions of 25%–233% 38 ✓ conserving energy by optimizing equipment use (switching off when not used, sleep-mode) can reduce emissions 53 ✓ investing in infrastructural solutions that maximise use on natural light (windows exposure) and minimizes the need for air-conditioning (insulation, reflective materials) 41 positive decarbonising the supply chain ✓ numerous studies showed that green procurement (e.g., using sustainable or local sources of food supply, or using supply chains with low emissions) can reduce emissions 53 positive *if available, quantitative data are presented; otherwise a descriptive information is used All 36 reviews on mitigation strategies focused on environmental impact (mostly GHG emissions) usually as a primary outcome measure, while 15 of them also included financial costs and/or quality of care as additional outcomes of interest. Among these, five reviews evaluated all three aspects simultaneously: impact on environment, costs and quality of care (Table 6 ). The majority of the existing evidence indicated that mitigation actions have a positive impact on environment (reduced emissions, waste) and costs (costs savings), as well as a positive or neutral impact on quality of care (e.g., mortality, surgical site infection, asthma control). Table 6 Results of the reviews on mitigation, with multiple outcome measures (15R) 1st author and ref. no Review’s topic Mitigation action’s impact on Environment Costs Quality of care Batcup 45 mix - behavioural change interventions positive positive n/a Blom 38 mix - different strategies / health system levels positive mostly positive mostly positive Carino 39 food waste (across hospital supply chain) positive positive n/a Chauvet 54 surgical operations - single vs multiuse laparoscopic instruments positive positive mixed Eussen 55 surgical operations - single vs multiuse instruments positive positive neutral Gumera 56 surgical operations - single vs multiuse headwear positive positive/ neutral neutral Iakovou 64 surgical operations - plastic surgery positive positive n/a Onasanya 67 pharmaceuticals - inhalers positive n/a positive Papadopoulou 43 surgical operations - minimally invasive surgery (robotic vs laparoscopic) mixed positive n/a Pickard Strange 50 telemedicine positive positive n/a Pickles 59 mix - different strategies / health system levels mostly positive mostly positive neutral Pitard 69 pharmaceuticals - hospital pharmacy (mix) positive mostly positive n/a Rodler 51 telemedicine positive positive n/a Roletto 60 radiology (mix) positive positive n/a Vu 62 surgical operations (mix) positive positive n/a Note: a positive outcome on costs implies lower costs for healthcare providers. 3.5. Evidence on the scope and effectiveness of climate resilience actions Among the four reviews on climate resilience (including one addressing both mitigation and adaptation actions) two focused on hospital disaster preparedness 41 , 42 , one on health workforce 14 and one on community heat adaptations actions 15 . Only the latter reported direct outcome measures (Table 7 ). Consequently, the evidence on the effectiveness of particular actions is largely descriptive. Multicomponent educational activities, targeting both health professionals and patients, were the most often reported form of adaptation strategy. Table 7 Synthesis of the identified adaptation actions (4R) Review’s theme Strategy/Action Hospital disaster preparedness: 2R, n = 48 ✓ continuous education of health care professionals on disaster preparedness, including multi-professional, scenario-based educational trainings 42 ✓ availability of disaster response protocols (including additional supplies availability patterns) developed and updated by the dedicated emergency preparedness committee 42 ✓ early warnings/ outbreaks detection IT systems 42 ✓ investing in climate-proof infrastructure solutions (e.g., insulation, reflective materials to reduce receiving heat inside buildings; architectural design to reduce risk of flooding, or damages due to strong winds) 41 Workforce preparedness: 1R, n = 60 ✓ disaster preparedness training (incl. actionable protocols, drills, evacuation plans and interprofessional collaboration) 14 ✓ planning for staff surge capacity (scheduling and contingency plans, effective mobilisation strategies, role flexibility and adequate incentives structure) 14 ✓ psychological support (counselling during and after climate events) 14 Community heat adaptations: 1R, n = 10 ✓ multicomponent educational interventions delivered in community settings (e.g., written and digital media, individual communication) can be effective in improving heat literacy, behavioural adaptation, and health outcomes (incl. reduced number of hospital visits, reduced heat related health events) 15 4. DISCUSSION To the best of our knowledge, this is the first umbrella review synthesizing systematic reviews on health system responses to climate change. Four main findings emerge. First, there is a large and rapidly growing evidence base: we identified 39 reviews published between 2020 and 2025, covering more than 900 primary studies, mostly originating from high-income countries. Second, the literature is strongly concentrated on mitigation strategies, while evidence on adaptation and climate resilience remains comparatively scarce. Most research focuses on actions implemented at the level of individual healthcare providers or clinical practices, with more than half addressing mitigation actions in surgical care, whereas other themes – including food waste, telemedicine and transport, radiology, pharmaceuticals, primary health care, behavioural interventions, and mixed strategies across health system levels – are each covered by only a small number of reviews. Third, the available evidence indicates that many mitigation actions generate environmental and economic co-benefits by simultaneously reducing emissions and costs, although much of the underlying research is of low to moderate quality. Emerging evidence further suggests that mitigation interventions have no – or maybe even a positive – impact on quality of care. Finally, several findings – particularly regarding reusable instruments and specific surgical techniques – appear to be highly context dependent. Our findings are in line with results of previous evidence syntheses focusing on climate mitigation strategies within health systems, e.g., Braithwaite et al. 53 and Seppänen & Or 19 . However, our work covers a broader literature base, reports on quality appraisal of both the systematic reviews and the underlying primary studies, provides more details on the effectiveness of particular strategies, and draws attention to (potential) co-benefits of interventions for environmental sustainability and costs. It provides the most comprehensive overview of the available literature to date. However, before discussing the implications for policy and research, several limitations should be noted. First, the evidence base shows substantial methodological heterogeneity. Across the included reviews, effectiveness data were reported in different formats (quantitative versus descriptive) and at different levels of aggregation (individual studies, pooled results, or fragmented summaries). Reviews also applied a wide range of quality appraisal and risk-of-bias tools – more than 30 different tools were used, up to four in a single review (Table S5 in Supplementary File). This limited comparability and prevented a quantitative synthesis or overall grading of evidence certainty. Second, many underlying primary studies were assessed as having low to moderate methodological quality, which reduces reliability of the results. Third, our inclusion criteria focused on reviews primarily addressing health system actions, while climate resilience often depends on intersectoral measures involving urban planning, transport, agriculture and food systems, energy, and housing. 7 , 75 ; relevant evidence from these areas may therefore not be fully captured. Finally, only a subset of reviews included life-cycle assessment (LCA) studies, which are considered the gold standard for evaluating environmental impacts 76 , 77 ; summary statistics of the available evidence could not be calculated as not all reviews reported methodological details about the included studies. These limitations highlight the need for more standardized methodologies and reporting practices in future research. Nevertheless, our findings have important implications for policymakers and researchers. First, the large body of available evidence provides practical guidance for reducing the environmental footprint of healthcare in several well-identified emission hotspots, including surgical care, radiology, pharmaceuticals, patient and staff transport, and food waste: Surgery is highly resource-intensive: it uses three to six times more energy than other hospital wards 78 , accounts for 30% to 50% of hospital waste, including mostly single-use plastic products and packaging 49 , 79 , and represents up to 60% of total hospital emissions 80 . Reducing the use of high-emission anaesthetic gases, improving operating room energy management, optimising surgical pathways, and increasing the use of reusable instruments can make a substantial contribution to environmental sustainability 49 ,79 81 . Pharmaceuticals account for about 25% of health system emissions 82 , 83 , with certain medicines having a disproportionate impact. For example, inhalers generate about 3% of total NHS emissions in England. Key mitigation approaches include reducing pharmaceutical waste and selecting medicines with lower environmental impact, such as switching from metered-dose to dry-powder inhalers where clinically appropriate. Clinical radiology and radiotherapy contribute about 10% of the healthcare carbon footprint 44 . The major drivers are energy-intensive equipment, large data storage needs, and waste from consumables, including radiological contrast agents 84 , 85 . Existing evidence suggests that 40% to 91% of energy use occurs during idle time, when devices are switched on but not operating 60 . In addition, there is growing evidence on low-value diagnostic imaging – including, for example, MRI and CT scans which are unnecessarily performed 86 , thus the potential for emission reduction is substantial. Food waste represents approximately 20% to 30% of total hospital waste, with plate waste averaging around 30%-40% 87 , but varying depending on the type of ward. When decomposed in landfills, food waste emits methane which has a global warming potential 28 times greater than carbon dioxide 88 . Mitigation actions for food waste in hospitals cover all areas of the general food recovery hierarchy 89 , with prevention of waste generation as the most effective approach. Transport and travel account for 14% to 22% of healthcare emissions 83 , 90 . Much of the existing mitigation evidence in this area focuses on telemedicine as an effective way to limit both patients and health professional transport. To achieve system-wide impact, these insights need to be translated into formal policy instruments such as clinical guidelines, procurement standards, and organisational sustainability strategies. Some examples already exist, The Green Surgery Report 91 by the UK Health Alliance on Climate Change, The Greening the Operating Room and Perioperative Arena guidelines 92 by the American Society of Anaesthesiologists, and Intensive Care Environmental Sustainability Recipe Book 93 by the Intensive Care Society. Second, the strong concentration of the literature on mitigation underlines the need for greater attention to climate adaptation in health systems. Climate change is already affecting health systems through heatwaves 94 , extreme weather events 95 , and changing disease patterns 96 , yet only a small number of systematic reviews addressed adaptation or resilience actions. While effective health system adaptation often requires coordination with other sectors—including urban planning, energy systems, and food systems 7 —the limited number of rigorous systematic reviews that assess the quality or certainty of the underlying evidence on heat adaptation, climate-resilient infrastructure, or green resilience approaches within healthcare is notable. Strengthening the evidence base in this area is therefore an important priority for both research and policy. Third, the evidence on environmental and economic co-benefits provides an important argument for policy action. Many mitigation strategies appear capable of simultaneously reducing greenhouse gas emissions and healthcare costs. In addition, emerging evidence – currently based on just a few reviews 55 , 56 , 59 – suggests that investigated mitigation actions have a neutral or maybe even positive impact on quality of care. For example, reviews by Eussen et al. 55 and Gumera et al. 56 showed that reusable medical instruments and reprocessed single use instruments (e.g., scissors, trocars, forceps, Veress needles) as well as reusable surgical headwear, offer significant environmental advantages and lower costs, while maintaining comparable performance and safety to disposable alternatives. Similarly, the review by Onasanya et al. 67 showed that switching to inhalers with much lower emissions was associated with improved inhaler adherence and asthma control. Consequently, policies that prioritise mitigation interventions may align climate objectives with broader health system goals, including cost containment and value-based care. Further research could usefully explore these co-benefits more systematically and examine the environmental implications of other cost-saving care strategies, such as shifting care to ambulatory settings and reducing low-value interventions. Existing efforts to incorporate environmental sustainability criteria (e.g. carbon emissions) in clinical trials 97 , 98 , or health technology assessments 99 , 100 and prioritising services that can provide the same health effect with lower environmental impact 101 are pointing in the right direction. Fourth, the environmental performance of specific interventions may vary considerably depending on local conditions such as energy sources, sterilization practices, reuse rates, or the organization of clinical pathways. For example, the relative environmental advantage of reusable vs. single-use medical instruments depends on a range of factors 40 , 47 , 57 , including the efficiency of sterilisation techniques (e.g., related to packing of autoclaves), the number of reuse cycles, and the proportion of renewable sources in the energy mix. Consequently, a similar mitigation action can be effective in one context and not in another. For example, the carbon footprint of reusable surgical instruments may be much higher in Australian settings (with mostly coal-based electricity) than in European ones (with a higher share of renewable energy sources) 40 . These findings suggest that policy guidance should combine general principles with context-specific assessments. Health systems may therefore benefit from integrating environmental impact evaluations into local decision-making processes, procurement strategies, and clinical pathway redesign. Fifth, our findings highlight the need to strengthen methodological standards and implementation capacity. The heterogeneity of environmental impact assessment methods across studies limits the comparability and synthesis of results. Wider use of standardized approaches – particularly LCAs – would improve the robustness of the evidence base. LCAs are based on dedicated ISO standards (ISO 14040–14044) 76 , 77 and allow for a comprehensive product assessment, from ‘cradle to grave’ (material extraction, production, use, and waste management). Furthermore, incorporating environmental impact indicators into standard health information and reporting systems would enable more systematic assessment of the environmental performance of healthcare activities, moving beyond the current reliance on ad hoc analyses conducted for individual studies. Finally, translating evidence into practice will require stronger integration of climate and sustainability topics into health professional education, clinical training, and continuing professional development programs. We found two reviews underlining the crucial role of educational activities, training and skill development for climate mitigation and adaptation efforts 14 , 45 . However, current training programs often do not cover climate action topics 102 – 104 . For example, in 2020 climate change topics were taught in only 15% of medical schools worldwide (survey by The International Federation of Medical Students Associations) 102 ; and surveys among intensive care professionals indicate that many lack formal training on environmentally sustainable practices 105 . Strengthening education and training in this area is therefore an important step toward enabling health professionals to incorporate environmentally sustainable practices into routine decision-making. At the same time, growing engagement among medical students and health professionals suggests increasing interest in this topic, providing a promising foundation for integrating climate and sustainability competencies into future health workforce training 106 , 107 . 5. CONCLUSIONS This is the first umbrella review synthesizing systematic reviews on health system responses to climate change. It shows that a substantial and rapidly growing body of research exists on health system responses to climate change. The literature is strongly concentrated on mitigation strategies implemented at the level of individual providers – particularly in surgical care – while evidence on adaptation and climate resilience remains comparatively scarce. Across several areas, mitigation actions appear capable of generating environmental and economic co-benefits by simultaneously reducing greenhouse gas emissions and healthcare costs – and some evidence suggests that these benefits can be achieved without compromising quality of care. At the same time, some findings—such as those related to reusable instruments or specific surgical techniques—are highly context dependent. These findings have important implications for policymakers and researchers: First, the existing evidence base provides practical guidance for reducing environmental impacts in key emission hotspots, including surgical care, radiology, pharmaceuticals, transport, and food waste, which can be incorporated into clinical guidelines, procurement standards, and organisational strategies. Second, the strong focus on mitigation highlights the need to strengthen the evidence base on climate adaptation and health system resilience. Third, the potential for environmental and economic co-benefits provides a strong rationale for policy action. Fourth, the context dependence of several interventions suggests that general policy guidance should be complemented by local environmental impact assessments. Finally, strengthening methodological standards (particularly LCA), more routine collection of environmental data, and incorporation of climate topics in health workforce training could support more systematic and evidence-informed climate action in health systems. Declarations Competing interest None. Funding No dedicated funding. References WHO. WHO guidance for climate resilient and environmentally sustainable health care facilities (2020) Accessed May 2, 2025. https://www.who.int/publications/i/item/9789240012226 WHO. Climate change (2023) Accessed May 2, 2025. https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health Health and Climate Change. 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Accessed March 10 (2026) https://ics.ac.uk/guidance/sustainability/ic-environmental-sustainability-recipe-book.html Psistaki K, Kouis P, Yiallouros PK, Paschalidou A (2025) Heatwave characteristics and health impacts: a review of epidemiological evidence and implications for heatwave response plans. Environ Research: Health 3(4):042003. 10.1088/2752-5309/ae1861 Valente M, Del Prete C, Facci G et al (2026) The impacts of extreme weather events on health services and systems: A systematic review of reviews. Public Health 250:106049. 10.1016/j.puhe.2025.106049 Wright AKA, Ezugwu CI, Iregbu JK et al (2025) Climate Change and Emerging Infectious Diseases: A Global Review of Shifting Patterns, Pathogens, and Public Health Risk. Epidemiol Health Data Insights 1(3):ehdi009. 10.63946/ehdi/16744 Nordberg LB, Pohl H, Haavardsholm EA, Lillegraven S, Bretthauer M (2024) Carbon-Footprint Analyses in RCTs — Toward Sustainable Clinical Practice. N Engl J Med 390(24):2234–2236. 10.1056/nejmp2402018 Petersen JJ, Hemberg L, Thabane L et al (2025) Integrating environmental outcomes in randomised clinical trials: a call to action. Lancet 405(10477):446–448. 10.1016/S0140-6736(24)02666-7 Williams JTW, Bell KJL, Morton RL, Dieng M (2024) Methods to Include Environmental Impacts in Health Economic Evaluations and Health Technology Assessments: A Scoping Review. Value Health 27(6):794–804. 10.1016/j.jval.2024.02.019 Desterbecq C, Tubeuf S (2023) Inclusion of Environmental Spillovers in Applied Economic Evaluations of Healthcare Products. Value Health 26(8):1270–1281. 10.1016/j.jval.2023.03.008 Identifying (2026) measuring and reducing low-value care in the context of health system performance assessment - Public Health. Accessed February 12. https://health.ec.europa.eu/publications/identifying-measuring-and-reducing-low-value-care-context-health-system-performance-assessment_en Climate C (2026) & Medical Schools | IFMSA. Accessed February 14. https://ifmsa.org/climate-change-medical-schools/ Bevan J, Blyth R, Russell B et al (2023) Planetary health and sustainability teaching in UK medical education: A review of medical school curricula. Med Teach 45(6):623–632. 10.1080/0142159X.2022.2152190 Luo OD, Carson JJK, Sanderson V, Wu K, Vincent R (2021) Empowering health-care learners to take action towards embedding environmental sustainability into health-care systems. Lancet Planet Health 5(6):e325–e326. 10.1016/S2542-5196(21)00059-0 Iliopoulou K, Leone M, Hunfeld N et al (2025) Environmental sustainability in intensive care: An international survey of intensive care professionals‘views, practices and proposals to the European Society of Intensive Care Medicine. J Crit Care 88(3):155079. 10.1016/j.jcrc.2025.155079 Létourneau S, Roshan A, Kitching GT et al (2023) Climate change and health in medical school curricula: A national survey of medical students’ experiences, attitudes and interests. J Clim Change Health 11(10):100226. 10.1016/j.joclim.2023.100226 Hampshire K, Ndovu A, Bhambhvani H, Iverson N (2021) Perspectives on climate change in medical school curricula—A survey of U.S. medical students. J Clim Change Health 4(12):100033. 10.1016/j.joclim.2021.100033 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9095097\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Systematic Review\",\"associatedPublications\":[],\"authors\":[{\"id\":604486850,\"identity\":\"c79a72ba-dff0-44f5-9936-27d9aeccf688\",\"order_by\":0,\"name\":\"Katarzyna 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process\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"groupimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9095097/v1/88d2c7cc7a2ab736e34ffac7.jpeg\"},{\"id\":104582680,\"identity\":\"4029aa7a-6168-4dea-b3da-9bf98859f40b\",\"added_by\":\"auto\",\"created_at\":\"2026-03-13 15:13:48\",\"extension\":\"jpeg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":314972,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eThe thematic scope of the included reviews (R)*\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e*colours: green – environmental sustainability (mitigation); orange – climate resilience (adaptation); grey – both mitigation and adaptation; the box’s size corresponds to the number of primary studies included in the reviews (n=1161 across all 39R)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9095097/v1/9919ea865df603ca27c040bc.jpeg\"},{\"id\":104782048,\"identity\":\"3c241cc9-57c8-4bce-aebe-0c28e4b1ea28\",\"added_by\":\"auto\",\"created_at\":\"2026-03-17 07:56:45\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2625010,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9095097/v1/0fa5ad69-995b-4649-b961-293992039379.pdf\"}],\"financialInterests\":\"The authors declare no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003e\\u003cstrong\\u003eHealth systems’ responses to climate change: an umbrella review of systematic reviews\\u003c/strong\\u003e\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"1. BACKGROUND\",\"content\":\"\\u003cp\\u003eClimate change is the most significant threat to human health globally \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR2\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e. It negatively affects population access to basic human needs, such as clean air and water, increases the burden of climate-related risk factors and diseases, and alters patterns of disease transmission \\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u003c/sup\\u003e. At the same time, the increasing frequency of extreme weather events (e.g., floods, hurricanes) disrupts health care delivery \\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e. Consequently, climate change impacts health systems by simultaneously increasing the demand for healthcare provision and impairing their ability to respond. Current prognoses predict that more severe climate risks will emerge sooner than previously expected \\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e, putting an enormous pressure on health systems to implement adequate response strategies \\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe health system response to climate change comprise two closely interdependent dimensions: 1) environmental sustainability, which aims at mitigating the negative impact of health systems on the environment by reducing its greenhouse gas (GHG) emissions, and 2) climate resilience, focusing on adaptations measures to better cope with the impact of climate-related shocks and stress \\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e. Within both dimensions, a variety of actions can be implemented at different levels of the health system, and their effectiveness can be assessed using diverse direct and indirect metrics (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The World Health Organization\\u0026rsquo;s (WHO) \\u0026ldquo;Operational framework for building climate resilient and low carbon health systems\\u0026rdquo; integrates both concepts into guidance on health system transformation \\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eConceptual framework of health system\\u0026rsquo;s response to climate change\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eDimension\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eHealth system\\u0026rsquo;s response to climate change\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eEnvironmental sustainability - MITIGATION\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eClimate resilience \\u0026ndash;\\u003c/p\\u003e \\u003cp\\u003eADAPTATION\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eFocus\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ereducing the negative impact of health systems on environment\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ebetter coping with the impact of climate change\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eExamples of actions\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; changes in clinical practice to reduce greenhouse gas emission,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; reducing low-value care,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; investments in renewable energy sources,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; more sustainable waste management,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; reducing health workforce travel,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; incorporating sustainability rules into procurement contracts\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026bull; implementing early warning systems,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; planning back-up systems for service delivery during climate-induced disasters,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; investing in climate-proofing of health infrastructure,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; training the health workforce in disaster management\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eExamples of effectiveness measures\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; reduction of greenhouse gas emissions (e.g. in kilograms (kg) per year or per specific health care service/product life cycle)\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; reductions in plastic waste or water usage per patient/procedure\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026bull; reduction in the number of deaths or people affected by climate-related disasters per 100,000 population,\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; reduction in heat-related excess mortality\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; reduction in frequency of healthcare provision disruption/infrastructure damage due to climate-related disasters\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"3\\\"\\u003eSource: Authors\\u0026rsquo; own compilation\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eHealth system responses to climate change have emerged as an important priority for health policy and research \\u003csup\\u003e\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e. Under the auspices of the WHO, The Alliance for Transformative Action on Climate and Health has brought together over 100 countries whose Ministers of Health have committed to strengthening the climate resilience of health systems and/or reducing their GHG emissions \\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e. Research on health system response to climate change has expanded significantly, with numerous reviews published in the last two years (2024\\u0026ndash;2025), including systematic \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR12 CR13 CR14 CR15\\\" citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e, rapid \\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e, scoping\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR20 CR21\\\" citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u003c/sup\\u003e, integrative\\u003csup\\u003e\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e\\u003c/sup\\u003e and/or narrative \\u003csup\\u003e\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u003c/sup\\u003e reviews. However, important gaps remain: Many systematic reviews focus only on a narrow aspect \\u0026ndash; for example environmental sustainability in a chosen medical discipline \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e or adaptation to heat related risks\\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e. In contrast, rapid, scoping and narrative reviews typically cover a broader range of actions but they do not conduct quality and/or risk of bias assessments of the underlying evidence. For evidence-informed health policy, however, the quality of the research evidence is crucial.\\u003c/p\\u003e \\u003cp\\u003eTo address these limitations, we conducted an umbrella review of systematic reviews on environmental sustainability and climate resilience actions in health systems, focusing on reviews that included a quality and/or risk of bias assessment of their underlying primary studies. Umbrella review are particularly valuable when several recent and still up-to-date systematic reviews on the topic are available \\u003csup\\u003e\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u003c/sup\\u003e. Our main goal was to offer decision makers a comprehensive and policy-relevant overview of the available evidence on environmental sustainability and climate resilience actions\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u003c/sup\\u003e. More specifically, the objectives were to: 1) characterize the main features of existing systematic reviews; 2) map the scope of available evidence on health system responses to climate change by geography, health system level, and type of response; and 3) synthesize evidence on the effectiveness of specific response strategies.\\u003c/p\\u003e\"},{\"header\":\"2. METHODS\",\"content\":\"\\u003cp\\u003eThe work followed the Joanna Briggs Institute (JBI) methodological guidelines for evidence synthesis in umbrella reviews \\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u003c/sup\\u003e and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist \\u003csup\\u003e\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e. The review was registered in PROSPERO (CRD420251052647) \\u003csup\\u003e\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e\\u003c/sup\\u003e, while its protocol was published in a peer-reviewed journal \\u003csup\\u003e\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.1. Review questions\\u003c/h2\\u003e \\u003cp\\u003eThree specific review questions were defined: 1) What are the main characteristics of the published systematic reviews?; 2) What is the scope of the available evidence on health system response to climate change (by geography, health system level, and type of response)?; 3) What evidence exists regarding the effectiveness of particular response strategies?\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.2. Inclusion and exclusion criteria\\u003c/h2\\u003e \\u003cp\\u003eWe defined inclusion and exclusion criteria using the PICOS (Population, Intervention, Comparison, Outcomes, Study design) framework \\u003csup\\u003e\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e\\u003c/sup\\u003e (see Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Broadly speaking, we included systematic reviews that examined health system responses to climate change, focusing on environmental sustainability and/or climate resilience. For both concepts, we applied the WHO definitions \\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e. In addition, systematic review had to meet the following quality criteria: 1) at least two databases were searched, and 2) a predefined instrument was used to assess the quality or risk of bias of the included studies.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eInclusion and exclusion criteria\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eElement\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eInclusion\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eExclusion\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eP - Population\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHealth system stakeholders at macro, mezzo, and micro levels (e.g. systematic reviews focusing on health systems as a whole or their subsectors e.g. hospital providers, general practice)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStudies with a primary focus outside the health system stakeholders (e.g., urban planning, agriculture)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eI - Intervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHealth system response to climate change, captured within: I - environmental sustainability (e.g., actions aimed at reducing greenhouse gas emissions), and/or II - climate resilience (e.g. actions aimed at improving preparedness for climate-induced disasters), using WHO definitions\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStudies focusing on the impact of the climate crisis on population health or changing disease patterns, changes in risk factors, changes in healthcare demand (e.g., increased hospital admissions).\\u003c/p\\u003e \\u003cp\\u003eStudies that measure the impact of HS on environment (without offering solutions on how to limit the negative impact or without comparing which solution is less harmful for the environment).\\u003c/p\\u003e \\u003cp\\u003eStudies addressing health system preparedness for non-climate-related disasters (e.g. terrorist attacks)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eC - Comparison\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNot applicable\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eNot applicable\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eO - Outcome\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOutcomes of response strategies, including: I \\u0026ndash; environmental sustainability measures (e.g., decreased carbon footprint measured in CO2e kg/year or reduced plastic waste in kg) and or II - climate resilience measures (e.g. health facility safety index, or chosen population/ health system-level indicators of climate resilience as defined by WHO)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStudies that focus on attitudes, barriers and facilitators to the health system response to climate change without the analysis of strategies outcomes/effectiveness (e.g., reviews focused on medical professional education, curricula content)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eS \\u0026ndash; Study design/type\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSystematic reviews (or other types of reviews) that report on the quality/risk of bias assessment of the included studies\\u003c/p\\u003e \\u003cp\\u003eMust be published in a peer-reviewed journal.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAny types of systematic literature reviews where quality assessment/risk of bias of the included studies was not conducted.\\u003c/p\\u003e \\u003cp\\u003eSystematic reviews not published in peer-reviewed journals.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.3. Search strategy\\u003c/h2\\u003e \\u003cp\\u003eIn July 2025, five databases were searched: 1) MEDLINE via PubMed, 2) Scopus, 3) Web of Science Core Collection, 4) ProQuest Central, and 5) Cochrane Database of Systematic Reviews. The search strategy was developed in accordance with the PRESS guidelines \\u003csup\\u003e\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e\\u003c/sup\\u003e and combined multiple terms related to climate change AND health system AND systematic review. Where available, a dedicated filter for systematic reviews was applied. Terms were searched as keywords in the title and/or abstract fields, and, when appropriate, Medical Subject Headings (MeSH) terms were also used. Prior to finalization, the strategy was tested across all five databases to ensure accuracy and relevance. We included studies published from 2015 onward, with full text available in English. Table S1 Supplementary File presents the full search strings for each database. In addition, the references of included studies were screened to identify additional systematic reviews that met the inclusion criteria.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.4. Selection of studies\\u003c/h2\\u003e \\u003cp\\u003eAll records were downloaded and deduplicated using Rayyan software\\u003csup\\u003e\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e\\u003c/sup\\u003e, which also supported the study selection process. This process involved two stages: 1) screening of titles and abstracts and 2) full-text assessment. Two researchers independently participated in both stages and evaluated the records/full texts according to the predefined inclusion and exclusion criteria (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Any discrepancies were resolved through consensus between the two researchers.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.5. Quality appraisal\\u003c/h2\\u003e \\u003cp\\u003eThe JBI critical appraisal checklist for systematic reviews and research syntheses\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u003c/sup\\u003e was used to assess the quality of included reviews. This tool, applicable to both quantitative and qualitative studies, contains eleven items rated as \\u0026lsquo;yes\\u0026rsquo;, \\u0026lsquo;no\\u0026rsquo;, \\u0026lsquo;unclear\\u0026rsquo;, or \\u0026lsquo;not applicable\\u0026rsquo;. A scoring guide specific to this umbrella review was developed, with \\u0026lsquo;yes\\u0026rsquo; scored as 1.0, \\u0026lsquo;unclear\\u0026rsquo; as 0.5, and \\u0026lsquo;no\\u0026rsquo; as 0.0. Reviews scoring above 75% were considered high quality, 50\\u0026ndash;75% moderate, and below 50% low quality. Table S2 in Supplementary File presents details of the appraisal matrix. Two researchers independently conducted the assessments and resolved discrepancies through consensus.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.6. Data extraction\\u003c/h2\\u003e \\u003cp\\u003eThe data extraction table was developed in an MS Excel file following JBI recommendations for umbrella reviews \\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u003c/sup\\u003e. It was pilot-tested on five included studies and revised as needed. The table included the following main sections: citation details; review questions; number of databases searched; date range of included studies; characteristics of included studies; quality appraisal; evidence certainty assessment; scope of climate action strategies; effectiveness of strategies; policy recommendations; additional notes. Two researchers independently extracted data, compared results, and resolved discrepancies through discussion. In the case of missing data the corresponding authors of included reviews were contacted with the request to provide relevant data.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.7. Data synthesis\\u003c/h2\\u003e \\u003cp\\u003eData were summarized using both quantitative and qualitative methods. Thematic analysis (both inductive and deductive) was used to summarize and map the identified mitigation and adaptation strategies. To identify the scope of overlapping publications (primary studies) across included systematic reviews the corrected covered area (CCA) was calculated following the Pieper at al. \\u003csup\\u003e36\\u003c/sup\\u003e method. The results of the quality appraisal of included systematic reviews, together with extracted data on evidence certainty (where available), were taken into consideration while drawing final conclusions and formulating policy recommendations \\u003csup\\u003e\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"3. RESULTS\",\"content\":\"\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.1. Search results\\u003c/h2\\u003e \\u003cp\\u003eThe search across the five scientific databases identified 4,433 records. After removing duplicates, 2,713 records were screened based on titles and abstracts, leading to 191 articles selected for full-text review. Of these, 37 publications met the inclusion criteria. The most common reason for exclusion was an inappropriate study design, usually related to the absence of quality appraisal of included studies in scoping reviews, or an unsuitable publication type \\u0026ndash; usually narrative reviews, where search results were not summarized (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Table S3 Supplementary File provides the full list of excluded studies along with the reasons for their exclusion. Two additional reviews were identified through reference list screening, resulting in a total of 39 included reviews (37 systematic reviews, one scoping review, and one integrative review\\u0026mdash;all meeting the criteria for study quality appraisal and reporting) (Table S4 in Supplementary File).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.2. General overview of the included reviews\\u003c/h2\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e presents a general overview of the included reviews. All 39 were published within the last five years (2020\\u0026ndash;2025). The vast majority (35/39) focused on environmental sustainability. Three reviews addressed climate adaptation actions, while one included primary studies examining both mitigation and adaptation strategies at the hospital level (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). The number of primary studies included in the reviews ranged from 8 to 205, while the total number of studies across all 39 reviews was 1,161 (933 after eliminating overlapping ones). The majority of reviews (21/39) included relatively new research (published since 2010) and applied language limitation to studies published solely in English (25/39). With the exemption of one \\u003csup\\u003e\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e\\u003c/sup\\u003e, all reviews included studies conducted either exclusively (23/39) or predominantly in high-income countries (15/39) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). The overall corrected covered area (CCA) ratio is 0.64%, (0.77% and 0.28% in the mitigation and adaptation groups, respectively) indicating only slight overlap of primary studies across the included reviews.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e*colours: green \\u0026ndash; environmental sustainability (mitigation); orange \\u0026ndash; climate resilience (adaptation); grey \\u0026ndash; both mitigation and adaptation; the box\\u0026rsquo;s size corresponds to the number of primary studies included in the reviews (n\\u0026thinsp;=\\u0026thinsp;1161 across all 39R)\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eGeneral overview of the included systematic reviews (chronological order)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"9\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c9\\\" colnum=\\\"9\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNo\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1st author and ref. no\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePublication year\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDimension*\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eReview\\u0026rsquo;s topic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNo of incl. stud.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eCountry of origin of incl. stud. (high- vs, middle, vs low-income countries)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003eThe date range of incl. studies\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003eQuality assessment result\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCarino \\u003csup\\u003e\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003efood waste in hospitals (across supply chain)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e80\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income, with the highest no. of studies from: US (19), UK (8), Denmark (8), Australia (5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1945\\u0026ndash;2018\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRizan \\u003csup\\u003e\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income: US (4), UK (2), Chile (1), India (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2011\\u0026ndash;2018\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMashallahi \\u003csup\\u003e\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM, A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003emix - hospitals mitigations and adaptation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e26\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income, with the highest no. of studies from: US (5), Australia (4), UK (4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2009\\u0026ndash;2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMohtady Ali \\u003csup\\u003e\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ehospital disaster preparedness\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e22\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, high-, middle and low-income countries. The highest no of studies from: US (4), Australia (3), China (3), UK (2), Sierra Leone (2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2006\\u0026ndash;2021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePapadopoulou \\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - minimally invasive surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income: US (9), Japan (2)\\u0026thinsp;+\\u0026thinsp;1 from Germany, Canada, France, India\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2005\\u0026ndash;2021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAnudjo \\u003csup\\u003e\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eradiology (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (5), The Netherlands (2), Switzerland (2)\\u0026thinsp;+\\u0026thinsp;1 from UK, Germany, Ireland, Canada, Australia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2015\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eBatcup \\u003csup\\u003e\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003emix - behavioural change interventions (in clinical settings)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: UK (15), US (3), Australia (2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2016\\u0026ndash;2021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCook \\u003csup\\u003e\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003efood waste in hospitals\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e85\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income, with the highest no. of studies from: US (37), Australia (15); Canada (9), UK (9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2002\\u0026ndash;2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eKeil \\u003csup\\u003e\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esingle-use vs reusable healthcare products (mostly within surgical operations)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e27\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income with the highest no of studies from: US (11), Australia (5), Germany (2), The Netherlands (2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2008\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLam \\u003csup\\u003e\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e21\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income with the highest no of studies from: US (11), UK (7), Australia (5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2012\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePerry \\u003csup\\u003e\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e34\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income with the highest no of studies from: US (18), Australia (6), UK (5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1994\\u0026ndash;2018\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePickard Strange \\u003csup\\u003e\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003etelemedicine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income, with the highest no of studies from: UK (8), US (7), Spain (2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1996\\u0026ndash;2021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRodler \\u003csup\\u003e\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003etelemedicine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e48\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income with the highest no of studies from: US (20); UK (12); Australia (5); Canada (3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2013\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eWicklum \\u003csup\\u003e\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePHC - decarbonisation toolkits (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income, with the highest no. of studies from: US (8), UK (7), Canada (4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2007\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eBlom \\u003csup\\u003e\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003emix - different strategies / health system levels\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e22\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMiddle income, with the highest no of studies from India (6), China (3), Malaysia (2), Pakistan (2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2000\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eBraithwaite 2024 \\u003csup\\u003e53\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003emix - different strategies / health system levels\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e205\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high income, with the highest no of studies from: US (27), UK (21), Australia (17), and Canada (14).\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2005\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eChauvet \\u003csup\\u003e\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse laparoscopic instruments\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (4), UK (3)\\u0026thinsp;+\\u0026thinsp;1 from Australia, Canada, Belgium, France, Germany, Greece, Switzerland\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1994\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCohen \\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations \\u0026ndash; obstetrics and gynaecology (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high income: US (11), Canada (2), UK (1), Netherlands (1), multi-country (2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2004\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e29\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDavies \\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (8), Canada (2), multi-country (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2010\\u0026ndash;2021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eEussen \\u003csup\\u003e\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse instruments\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e53\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income, with the highest no. of studies from: US (15), Germany (10), UK (7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1991\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e21\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eGumera \\u003csup\\u003e\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse headwear\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (8), the Netherlands (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2017\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e22\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eKloevekorn \\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (6), UK (3), Australia (2), Canada (2)\\u0026thinsp;+\\u0026thinsp;1 from Turkey, France, Spain, Denmark, Ireland\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2018\\u0026ndash;2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e23\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMartins \\u003csup\\u003e\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse instruments in minimally invasive procedures\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh-income: Denmark (3), US (3), Australia (2)\\u0026thinsp;+\\u0026thinsp;1 from France, Ireland, Sweden, UK, Germany\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2005\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNolan \\u003csup\\u003e\\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - behavioural interventions on anaesthetic agents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: UK (9), US (2)\\u0026thinsp;+\\u0026thinsp;1 from Australia, New Zealand\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2011\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePickles \\u003csup\\u003e\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003emix - different strategies / health system levels\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e21\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income, with the highest no of studies from: US (7), UK (6), Australia (3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2011\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e26\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRoletto \\u003csup\\u003e\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eradiology (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (7), Switzerland (3), UK (2), + 1 from Ireland, Canada, Australia, Germany\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2010\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e27\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003evan der Zee \\u003csup\\u003e\\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003etelemedicine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e28\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income with the highest no of studies from: UK (10); US (10); Australia (2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2010\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e28\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eVu \\u003csup\\u003e62\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (7), Canada (3), France (2), Portugal (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2010\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e39\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCunha \\u003csup\\u003e\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - abdominal surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (5), UK (2), Italy (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2008\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e30\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eIakovou \\u003csup\\u003e\\u003cspan citationid=\\\"CR64\\\" class=\\\"CitationRef\\\"\\u003e64\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - plastic surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: US (10), UK (3), Chile (1), Switzerland (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2017\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e31\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eJohar \\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ecommunity-based heat adaptation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high income: Australia (2), Japan (2), China (2) + 1 from US, Canada, Italy, Pakistan\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2000\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e32\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHammer \\u003csup\\u003e\\u003cspan citationid=\\\"CR65\\\" class=\\\"CitationRef\\\"\\u003e65\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - anaesthetic agents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: France (3), US (4), Germany (2), Switzerland (1), Singapore (1), South Korea (1), Australia (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2019\\u0026ndash;2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e33\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNunes \\u003csup\\u003e\\u003cspan citationid=\\\"CR66\\\" class=\\\"CitationRef\\\"\\u003e66\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePHC \\u0026ndash; decarbonisation (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: UK (5), Australia (3), US (2), Germany (2)\\u0026thinsp;+\\u0026thinsp;1 from France, Switzerland, Israel\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2016\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e34\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOnasanya \\u003csup\\u003e\\u003cspan citationid=\\\"CR67\\\" class=\\\"CitationRef\\\"\\u003e67\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003epharmaceuticals - inhalers\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e64\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high income with the highest no of studies from UK (24)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2014\\u0026ndash;2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePeyrottes \\u003csup\\u003e\\u003cspan citationid=\\\"CR68\\\" class=\\\"CitationRef\\\"\\u003e68\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse instruments in urological endoscopic procedures\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: Australia (3), France (3)\\u0026thinsp;+\\u0026thinsp;1 from Canada, Ireland, UK, US\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2018\\u0026ndash;2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e36\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePitard \\u003csup\\u003e\\u003cspan citationid=\\\"CR69\\\" class=\\\"CitationRef\\\"\\u003e69\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003epharmaceutical - hospital pharmacy (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income: France (4), US (4), Ethiopia (2), Saudi Arabia (2)\\u0026thinsp;+\\u0026thinsp;1 from England, Italy, Netherlands, Brazil, Spain.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2014\\u0026ndash;2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e37\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTozsin \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse instrument in urological procedures\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh income: France (3), US (2), Italy (2), Ireland (2), UK (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2018\\u0026ndash;2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003emoderate\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e38\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eZurynski \\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ehealth workforce preparedness\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e60\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMixed, mostly high-income, with the highest no. of studies from: US (29), Australia (6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2004\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e39\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003evan Nieuwenhuizen \\u003csup\\u003e70\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eM\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003esurgical operations (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e42\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigh-income, with the highest no. of studies from: US (20), Australia (4), UK (3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e2012\\u0026ndash;2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003ehigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"9\\\"\\u003e*M - mitigation, A - adaptation\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.3. Quality of the evidence base\\u003c/h2\\u003e \\u003cp\\u003eMore than half (23/39) of the included reviews were of high quality, while the remaining reviews were classified as being of moderate quality. Overall, the average quality score was 77%. The three most common quality problems were (1) lack of clearly and explicitly stated review question (28/39); (2) inclusion criteria not based on a dedicated framework (e.g., PICO) (22/39); and (3) searches conducted in fewer than five databases (23/39) (Table S2 in Supplementary File).\\u003c/p\\u003e \\u003cp\\u003eIn 23 reviews, a single instrument/checklist was used to assess the quality and/or risk of bias of the included primary studies, while in the remaining 16 reviews, between two and four different instruments were used (depending on the type of primary studies). In most reviews, the results of quality appraisal/risk of bias assessment of individual studies varied considerably. In only two reviews \\u003csup\\u003e\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e\\u003c/sup\\u003e, the pooled, overall quality score was above 80%, while in the vast majority of cases, the results were not pooled, only presented for each individual primary study and ranged from low or moderate to high quality/risk of bias. In two reviews \\u003csup\\u003e\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e\\u003c/sup\\u003e, studies of low quality were excluded from the data synthesis. In three reviews \\u003csup\\u003e\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR70\\\" class=\\\"CitationRef\\\"\\u003e70\\u003c/span\\u003e\\u003c/sup\\u003e, the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)\\u003csup\\u003e\\u003cspan citationid=\\\"CR71\\\" class=\\\"CitationRef\\\"\\u003e71\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR72\\\" class=\\\"CitationRef\\\"\\u003e72\\u003c/span\\u003e\\u003c/sup\\u003e approach, and in all three cases the overall certainty of evidence was rated as low (Table S5 in Supplementary File).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.4. Evidence on the scope and effectiveness of environmental sustainability actions\\u003c/h2\\u003e \\u003cp\\u003eThe 36 reviews on mitigation strategies (including one addressing both mitigation and adaptation) focused on eight main themes (see Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). More than half concentrated on different types of surgical operations (20/36). Other themes included food waste, telemedicine, radiology, pharmaceuticals, primary health care, behavioural interventions, and mixed strategies at different health system levels, each addressed in in two or three reviews.\\u003c/p\\u003e \\u003cp\\u003eThe identified mitigation strategies can be clustered into five main dimensions based on Braithwaite at al. \\u003csup\\u003e53\\u003c/sup\\u003e, including: 1) optimizing energy use in buildings and equipment (e.g., switching to renewable energy sources, turning off the equipment when not in use); 2) changing clinical care to reduce environmental impact (e.g., moving away from anaesthetic gases with high global warming potential; choosing medical pathways with lower environmental impact; reducing low-value care, implementing water saving measures); 3) reducing waste and improving its management (e.g., replacing single-use medical instruments and protective materials by multi-use options; waste reduction, reuse and recycling; recovering energy from waste); 4) reducing travel and transport (e.g., telemedicine, scheduling consultation to minimize patient travel, remote professional cooperation); and 5) reducing supply chain emissions (e.g., through local and green procurement) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eReviews\\u0026rsquo; themes and mitigation actions dimension matrix\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReview\\u0026rsquo;s theme / Mitigation dimension\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOptimizing energy use in buildings \\u0026amp; equipment\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eChanging clinical care to reduce impact on environment\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eReducing waste and improving its management\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eReducing travel and transport\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eReducing supply chain emissions\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSurgical operations: 20R, n\\u0026thinsp;=\\u0026thinsp;365\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFood waste: 2R, n\\u0026thinsp;=\\u0026thinsp;165\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTelemedicine: 3R, n\\u0026thinsp;=\\u0026thinsp;99\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRadiology: 2R, n\\u0026thinsp;=\\u0026thinsp;30\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePharmaceuticals: 2R, n\\u0026thinsp;=\\u0026thinsp;81\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePHC: 2R, n\\u0026thinsp;=\\u0026thinsp;35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBehavioural interventions: 1R, n\\u0026thinsp;=\\u0026thinsp;20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMix - different strat. /system levels: 4R, n\\u0026thinsp;=\\u0026thinsp;274\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e✓\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e presents a general overview of the identified mitigation strategies (as classified in reviews) and the available evidence on their effectiveness. For the vast majority of identified strategies, the results clearly indicated a positive impact on the environment, manifested as reduced GHG emissions and/or reduced waste or water use. However, for two types of actions: 1) replacing single-use medical instruments (used mostly in surgical procedures) by reusable alternatives, and 2) selecting a surgical technique with lower emissions (mostly robot-assisted versus laparoscopic) \\u0026ndash; the evidence was mixed. While most high quality studies reported significant environmental advantages of reusable surgical instruments \\u003csup\\u003e\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e\\u003c/sup\\u003e, some studies suggested the opposite \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e or found no differences in carbon footprint between single and multiuse instruments \\u003csup\\u003e\\u003cspan citationid=\\\"CR68\\\" class=\\\"CitationRef\\\"\\u003e68\\u003c/span\\u003e\\u003c/sup\\u003e. Similarly, some studies indicated lower GHG emissions from robot-assisted surgeries compared to laparoscopic ones \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e\\u003c/sup\\u003e, while others reported the opposite result \\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab5\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSynthesis of the identified mitigation actions and their effectiveness (36R)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReview\\u0026rsquo;s theme\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStrategy/Action\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eEvidence on effectiveness*\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eImpact on environment\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"6\\\" rowspan=\\\"7\\\"\\u003e \\u003cp\\u003eSurgical operations: 20R, n\\u0026thinsp;=\\u0026thinsp;365\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003emoving away from anaesthetic gases with high global warming potential (GWP)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ reduction of volatile anaesthetics, especially desflurane, lead to decrease in CO2e emissions between a 24% and a 98% \\u003csup\\u003e65\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ 12 out of 13 included studies reported reduced CO2e after application of educational interventions e.g., encouraging lowering fresh gas flow, applying intravenous anaesthesia \\u003csup\\u003e\\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ use of sevoflurane or propofol resulted in up to 60% reduced GHG emissions versus desflurane use \\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ converting all suitable procedures from general to spinal anaesthesia can generate substantial CO2e savins \\u003csup\\u003e\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eoptimizing energy use in operating theatres (OR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ turning off airflow systems during nights and weekends can save up to 70% of total energy use \\u003csup\\u003e\\u003cspan citationid=\\\"CR70\\\" class=\\\"CitationRef\\\"\\u003e70\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ installing occupancy sensors, low-energy lighting, energy efficient air-conditioning systems and water cooling systems showed significantly reduced carbon emission \\u003csup\\u003e\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ turning off idle sterilizers reduced electricity by 26% and water use by 13% \\u003csup\\u003e49\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ installing occupancy sensors in the OR let do decreased CO2 emissions by 234.2 tons \\u003csup\\u003e\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ereplacing single-use medical instruments with multi-use options\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ using reusable items showed a 70% waste reduction, 3 times lower water use, and 2.5 times lower energy consumption than disposables; disposable steel scissors had 99% higher environmental impact than reusable ones \\u003csup\\u003e\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ hybrid devices in laparoscopic cholecystectomy emitted less CO2e than single-use devices (1.8 vs. 7.2kg) \\u003csup\\u003e\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ 7 out of 8 studies showed lower environmental impact when using reusable endoscopic instruments \\u003csup\\u003e\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ 3 high quality life cycle assessment studies (LCA) showed that multiuse instruments have a significantly lower (2\\u0026ndash;26 times) environmental footprint than their single-use counterparts in minimally invasive surgeries; several fair/poor quality studies favoured single-use \\u003csup\\u003e\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ reusable equipment reduced CO2 emissions by 40\\u0026ndash;66% compared to single-use equivalents \\u003csup\\u003e\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ single-use cystoscopes had lower emissions per procedure (2.4\\u0026nbsp;kg) compared to their reusable counterparts (4.2 kg) but produced more waste; reusable cystoscopes, while having a lower cumulative waste per use, increased emissions due to energy-intensive reprocessing (the cumulative emissions results may depend on the sterilisation techniques and must be analysed by LCA) \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ in ureteroscopy, studies tend to show comparable carbon footprints for single-use and reusable instruments \\u003csup\\u003e\\u003cspan citationid=\\\"CR68\\\" class=\\\"CitationRef\\\"\\u003e68\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ minimal material and maximum reuse of equipment during hysterectomy resulted in 69% GHG emission reduction \\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003emixed\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eminimising waste produced by instruments packaging\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ repackaging of disposable instruments into packs of essential items customized to laparoscopic gynaecological surgery at their institution, resulting in waste reduction of 400 g per case \\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ using \\u0026lsquo;green packs\\u0026rsquo; for \\u0026lsquo;wide awake local anaesthesia no tourniquet\\u0026rsquo; cases showed a significant waste reduction (2.3 kg per case)\\u003csup\\u003e\\u003cspan citationid=\\\"CR64\\\" class=\\\"CitationRef\\\"\\u003e64\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ redesigning of hand surgery packs led to a 2.8 tonnes waste decrease \\u003csup\\u003e\\u003cspan citationid=\\\"CR64\\\" class=\\\"CitationRef\\\"\\u003e64\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ereplacing single-use medical protective materials (e.g., headwear) by multi-use options\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ reusable surgical head covers demonstrated a statistically significant lower carbon footprint, ozone depletion, fossil fuel depletion, terrestrial acidification, and fine particulate matter formation than disposable alternatives, while not impacting the surgical site infection rates \\u003csup\\u003e\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003echanging surgical techniques to those with lower environmental impact\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ robot-assisted surgery had a higher environmental impact than laparoscopic and open surgery \\u003csup\\u003e\\u003cspan citationid=\\\"CR70\\\" class=\\\"CitationRef\\\"\\u003e70\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ 2 studies on hysterectomy showed that robotic surgery had the highest emissions (12.0\\u0026ndash;40.3 kg CO2e) compared to laparoscopic (10.7\\u0026ndash;29.2 kgCO2e) and open surgery (7.1\\u0026ndash;22.7 kgCO2e); 1 study showed that laparoscopic prostatectomy produced more emissions than robotic option (59.7 vs. 47.3 kgCO2e) due to higher disposable devices, longer surgery time and length of stay \\u003csup\\u003e\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ robotic prostatectomy produced lower emissions than laparoscopic methods \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ using alcohol-based scrub limits water use (18.5 litres per person per scrub) \\u003csup\\u003e\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ increasing the lifetime of multi-use devices and fully loading autoclaves for their sterilization further decrease their environmental impact \\u003csup\\u003e\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ reducing custom pack contents and replacing single-use items reduced caesarean procedure footprint by 22% \\u003csup\\u003e16\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003emixed\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eimproving waste management\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ increasing recycling resulted in a 2% reduction in greenhouse gas emissions \\u003csup\\u003e\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ waste segregation/recycling and minimising unused supplies reduced emissions \\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ installing paper and cardboard recycling bins in anaesthetic room and operating theatre increased recycling (up to 50%-67% waste) \\u003csup\\u003e\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ educational campaign reduced infectious medical waste by 75% \\u003csup\\u003e48\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003eFood waste: 2R, n\\u0026thinsp;=\\u0026thinsp;165\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003echoosing local suppliers/procurement\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ using local food (direct 'farm to hospital' procurement), which limits transport, is most environmentally beneficial \\u003csup\\u003e\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eusing food ingredients and preparation techniques with lower environmental impact\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ mediterranean-style diets and vegetarian menu generated lower GHG emissions and water use than the standard menu \\u003csup\\u003e\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ using lean process tools reduced pre-service waste by 50%; fortified small portions decreases food waste by 5% \\u003csup\\u003e39\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eadopting consumption methods that minimize waste\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ using bulk trolley instead of plating food in the kitchen; enabling patient choice (e.g., room-service model) and using porcelain plates instead of plastic trays reduced food waste by 8% \\u003csup\\u003e39\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eimproving food waste management\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ composting waste and donating surplus food substantially decreased total food waste volume \\u003csup\\u003e\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ most strategies that avoid and/or reduce sending food waste to landfill (e.g., industrial use, feeding animals, worm farms) helped to limit GHG emissions\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTelemedicine: 3R, n\\u0026thinsp;=\\u0026thinsp;99\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eimplementing remote (telephone and video) consultations\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ all studies across all three reviews showed that telemedicine reduces GHG emissions due to limited travel (though not all included primary studies calculated telemedicine emissions) \\u003csup\\u003e\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ although limited, the studies where complete LCA of telemedicine solutions was performed also showed GHG emission reduction due to replacing face-to-face visit with remote options \\u003csup\\u003e\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eRadiology: 2R, n\\u0026thinsp;=\\u0026thinsp;30\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eoptimizing energy use\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ turning off workstations/devices after hours saved a substantial part of total energy \\u003csup\\u003e\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ choosing energy efficient radiological equipment \\u003csup\\u003e\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ereducing the use of consumables and radiopharmaceuticals\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ limiting the use of diatrizoic acid (contrast agent) reduced environmental contaminations (e.g. in rivers) \\u003csup\\u003e\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ereducing patients\\u0026rsquo; and staff travel\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ investing in teleradiology/remote collaboration - online conferences (e.g., switching to online, the annual Radiological Society of North America conference can save 40\\u0026nbsp;000 tons of CO2e due to travel) \\u003csup\\u003e44\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003ePharmaceuticals: 2R, n\\u0026thinsp;=\\u0026thinsp;81\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ereducing pharmaceutical waste\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ diversity of actions described as effective, including e.g.: educational interventions (for both patients and staff); providing information (audit and feedback on waste values; monthly bulletins of waste production); reminders to return unused medicines; changing dispensing/distribution practice (dosage on demand; increased frequency of batches preparation), incorporating of environmental sustainability rules into procurement contracts \\u003csup\\u003e\\u003cspan citationid=\\\"CR67\\\" class=\\\"CitationRef\\\"\\u003e67\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR69\\\" class=\\\"CitationRef\\\"\\u003e69\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eswitching to pharmaceuticals with lower carbon footprint\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ switching inhalers from metered-dose (MDI) to dry powder inhalers (DPI) significantly lowered the carbon footprint while at the same time improved asthma control and adherence \\u003csup\\u003e\\u003cspan citationid=\\\"CR67\\\" class=\\\"CitationRef\\\"\\u003e67\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003ePHC: 2R, n\\u0026thinsp;=\\u0026thinsp;35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003edelivering PHC\\u0026rsquo;s decarbonisation toolkits\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ 11 toolkits were identified, all including educational materials for PHC staff, while 7 also included resources for patients; majority focused on clinical operations, procurement, energy use, and waste and recycling \\u0026ndash; although quantitative data were limited, the available evidence pointed towards a reduced environmental impact after toolkits implementation \\u003csup\\u003e\\u003cspan citationid=\\\"CR73\\\" class=\\\"CitationRef\\\"\\u003e73\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eimplementing mix of actions, incl.: reuse of resources, improving waste management, revising prescriptions; saving energy; promoting telemedicine and health education\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ no quantitative data were provided and the identified strategies\\u0026rsquo; results were not consistently reported; some strategies proved effective in reducing emissions (e.g., energy efficient solution; limiting patient travel by telemedicine and changes in appointment scheduling and prescription collection; social prescribing reduced further health care use, switching to dry powder inhalers reduced emissions) \\u003csup\\u003e\\u003cspan citationid=\\\"CR74\\\" class=\\\"CitationRef\\\"\\u003e74\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBehavioural interventions: 1R, n\\u0026thinsp;=\\u0026thinsp;20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eimplementing a mix of behaviour change techniques, incl.: change in policy/protocols, email updates, announcements, presentations, personalised and team feedback, reminder notes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ some strategies, especially comprehensive ones that applied more than one behavioural technique proved effective in reducing emissions, with most evidence focused on interventions that targeted anaesthesia and pathology test ordering in hospital settings, e.g., educational intervention on anaesthetic gases flow rate in perioperative settings showed 105 kg of CO2e reduction per case; behavioural intervention to reduce biochemical test ordering showed 10 tons of CO2e reduction per year \\u003csup\\u003e\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e \\u003cp\\u003eMix - different strategies / health system levels: 4R, n\\u0026thinsp;=\\u0026thinsp;274\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003echanging clinical and surgical care pathways to reduce environmental impact\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ interventions related to changing anaesthesia agent practices can lead to GHG reduction between 25% \\u0026minus;\\u0026thinsp;100% \\u003csup\\u003e59\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ targeting unnecessary resting (low-value care) limited emissions by 10%-37% \\u003csup\\u003e59\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ implementing multicomponent interventions to reduce low-value care (incl.: identifying and reducing unnecessary processes or procedures, minimising drug overprescription, encouraging a preventative care approach to reduce the need for health services) can successfully reduce emissions \\u003csup\\u003e\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ implementing water use saving plans (e.g., automatic shut-off / low pressure valves, reporting water use to staff) can reduce water consumption \\u003csup\\u003e\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ereducing waste volume and improving waste managements\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ multicomponent waste reduction intervention incl. clinician education, audit and feedback, recycling, relocation of landfill, and converting from single-use to reusable sharps containers led to reducing GHG emission by 32%-85% \\u003csup\\u003e59\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ systems integrating waste segregation, composting and material recycling with simultaneous transport optimisation generated greatest emission reductions, ranging from 47%\\u0026ndash;114% \\u003csup\\u003e38\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ereducing travel and transport\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ numerous studies examining different approaches to reduce travel and transportation (telemedicine, local care options, shared transport options, scheduling face-to-face appointment to minimize travel needs, reducing health professional\\u0026rsquo;s business trips) showed positive results in terms on GHG emission reductions \\u003csup\\u003e\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eoptimizing energy use (in buildings and equipment)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ using a mixed energy sources or fully renewable once, led to CO2 emission reductions of 25%\\u0026ndash;233% \\u003csup\\u003e38\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ conserving energy by optimizing equipment use (switching off when not used, sleep-mode) can reduce emissions\\u003csup\\u003e\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ investing in infrastructural solutions that maximise use on natural light (windows exposure) and minimizes the need for air-conditioning (insulation, reflective materials) \\u003csup\\u003e\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003edecarbonising the supply chain\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e✓ numerous studies showed that green procurement (e.g., using sustainable or local sources of food supply, or using supply chains with low emissions) can reduce emissions \\u003csup\\u003e\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e*if available, quantitative data are presented; otherwise a descriptive information is used\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eAll 36 reviews on mitigation strategies focused on environmental impact (mostly GHG emissions) usually as a primary outcome measure, while 15 of them also included financial costs and/or quality of care as additional outcomes of interest. Among these, five reviews evaluated all three aspects simultaneously: impact on environment, costs and quality of care (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab6\\\" class=\\\"InternalRef\\\"\\u003e6\\u003c/span\\u003e). The majority of the existing evidence indicated that mitigation actions have a positive impact on environment (reduced emissions, waste) and costs (costs savings), as well as a positive or neutral impact on quality of care (e.g., mortality, surgical site infection, asthma control).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab6\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 6\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eResults of the reviews on mitigation, with multiple outcome measures (15R)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003e1st author and ref. no\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eReview\\u0026rsquo;s topic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c5\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003eMitigation action\\u0026rsquo;s impact on\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eEnvironment\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCosts\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eQuality of care\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBatcup \\u003csup\\u003e\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003emix - behavioural change interventions\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBlom \\u003csup\\u003e\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003emix - different strategies / health system levels\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003emostly positive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003emostly positive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCarino \\u003csup\\u003e\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003efood waste (across hospital supply chain)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChauvet \\u003csup\\u003e\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse laparoscopic instruments\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003emixed\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEussen \\u003csup\\u003e\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse instruments\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eneutral\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGumera \\u003csup\\u003e\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003esurgical operations - single vs multiuse headwear\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive/\\u003c/p\\u003e \\u003cp\\u003eneutral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eneutral\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIakovou \\u003csup\\u003e\\u003cspan citationid=\\\"CR64\\\" class=\\\"CitationRef\\\"\\u003e64\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003esurgical operations - plastic surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOnasanya \\u003csup\\u003e\\u003cspan citationid=\\\"CR67\\\" class=\\\"CitationRef\\\"\\u003e67\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003epharmaceuticals - inhalers\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePapadopoulou \\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003esurgical operations - minimally invasive surgery (robotic vs laparoscopic)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003emixed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePickard Strange \\u003csup\\u003e\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003etelemedicine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePickles \\u003csup\\u003e\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003emix - different strategies / health system levels\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003emostly positive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003emostly positive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eneutral\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePitard \\u003csup\\u003e\\u003cspan citationid=\\\"CR69\\\" class=\\\"CitationRef\\\"\\u003e69\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003epharmaceuticals - hospital pharmacy (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003emostly positive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRodler \\u003csup\\u003e\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003etelemedicine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRoletto \\u003csup\\u003e\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eradiology (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVu \\u003csup\\u003e62\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003esurgical operations (mix)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003epositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en/a\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"5\\\"\\u003eNote: a positive outcome on costs implies lower costs for healthcare providers.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.5. Evidence on the scope and effectiveness of climate resilience actions\\u003c/h2\\u003e \\u003cp\\u003eAmong the four reviews on climate resilience (including one addressing both mitigation and adaptation actions) two focused on hospital disaster preparedness \\u003csup\\u003e\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e\\u003c/sup\\u003e, one on health workforce\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e and one on community heat adaptations actions \\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e. Only the latter reported direct outcome measures (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab7\\\" class=\\\"InternalRef\\\"\\u003e7\\u003c/span\\u003e). Consequently, the evidence on the effectiveness of particular actions is largely descriptive. Multicomponent educational activities, targeting both health professionals and patients, were the most often reported form of adaptation strategy.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab7\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 7\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSynthesis of the identified adaptation actions (4R)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReview\\u0026rsquo;s theme\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStrategy/Action\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHospital disaster preparedness: 2R, n\\u0026thinsp;=\\u0026thinsp;48\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e✓ continuous education of health care professionals on disaster preparedness, including multi-professional, scenario-based educational trainings \\u003csup\\u003e\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ availability of disaster response protocols (including additional supplies availability patterns) developed and updated by the dedicated emergency preparedness committee \\u003csup\\u003e\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ early warnings/ outbreaks detection IT systems \\u003csup\\u003e\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ investing in climate-proof infrastructure solutions (e.g., insulation, reflective materials to reduce receiving heat inside buildings; architectural design to reduce risk of flooding, or damages due to strong winds) \\u003csup\\u003e41\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWorkforce preparedness: 1R, n\\u0026thinsp;=\\u0026thinsp;60\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e✓ disaster preparedness training (incl. actionable protocols, drills, evacuation plans and interprofessional collaboration) \\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ planning for staff surge capacity (scheduling and contingency plans, effective mobilisation strategies, role flexibility and adequate incentives structure) \\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003e✓ psychological support (counselling during and after climate events) \\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCommunity heat adaptations: 1R, n\\u0026thinsp;=\\u0026thinsp;10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e✓ multicomponent educational interventions delivered in community settings (e.g., written and digital media, individual communication) can be effective in improving heat literacy, behavioural adaptation, and health outcomes (incl. reduced number of hospital visits, reduced heat related health events) \\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"4. DISCUSSION\",\"content\":\"\\u003cp\\u003eTo the best of our knowledge, this is the first umbrella review synthesizing systematic reviews on health system responses to climate change. Four main findings emerge. First, there is a large and rapidly growing evidence base: we identified 39 reviews published between 2020 and 2025, covering more than 900 primary studies, mostly originating from high-income countries. Second, the literature is strongly concentrated on mitigation strategies, while evidence on adaptation and climate resilience remains comparatively scarce. Most research focuses on actions implemented at the level of individual healthcare providers or clinical practices, with more than half addressing mitigation actions in surgical care, whereas other themes \\u0026ndash; including food waste, telemedicine and transport, radiology, pharmaceuticals, primary health care, behavioural interventions, and mixed strategies across health system levels \\u0026ndash; are each covered by only a small number of reviews. Third, the available evidence indicates that many mitigation actions generate environmental and economic co-benefits by simultaneously reducing emissions and costs, although much of the underlying research is of low to moderate quality. Emerging evidence further suggests that mitigation interventions have no \\u0026ndash; or maybe even a positive \\u0026ndash; impact on quality of care. Finally, several findings \\u0026ndash; particularly regarding reusable instruments and specific surgical techniques \\u0026ndash; appear to be highly context dependent.\\u003c/p\\u003e \\u003cp\\u003eOur findings are in line with results of previous evidence syntheses focusing on climate mitigation strategies within health systems, e.g., Braithwaite et al. \\u003csup\\u003e53\\u003c/sup\\u003e and Sepp\\u0026auml;nen \\u0026amp; Or \\u003csup\\u003e19\\u003c/sup\\u003e. However, our work covers a broader literature base, reports on quality appraisal of both the systematic reviews and the underlying primary studies, provides more details on the effectiveness of particular strategies, and draws attention to (potential) co-benefits of interventions for environmental sustainability and costs. It provides the most comprehensive overview of the available literature to date.\\u003c/p\\u003e \\u003cp\\u003eHowever, before discussing the implications for policy and research, several limitations should be noted. First, the evidence base shows substantial methodological heterogeneity. Across the included reviews, effectiveness data were reported in different formats (quantitative versus descriptive) and at different levels of aggregation (individual studies, pooled results, or fragmented summaries). Reviews also applied a wide range of quality appraisal and risk-of-bias tools \\u0026ndash; more than 30 different tools were used, up to four in a single review (Table S5 in Supplementary File). This limited comparability and prevented a quantitative synthesis or overall grading of evidence certainty. Second, many underlying primary studies were assessed as having low to moderate methodological quality, which reduces reliability of the results. Third, our inclusion criteria focused on reviews primarily addressing health system actions, while climate resilience often depends on intersectoral measures involving urban planning, transport, agriculture and food systems, energy, and housing.\\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR75\\\" class=\\\"CitationRef\\\"\\u003e75\\u003c/span\\u003e\\u003c/sup\\u003e; relevant evidence from these areas may therefore not be fully captured. Finally, only a subset of reviews included life-cycle assessment (LCA) studies, which are considered the gold standard for evaluating environmental impacts \\u003csup\\u003e\\u003cspan citationid=\\\"CR76\\\" class=\\\"CitationRef\\\"\\u003e76\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR77\\\" class=\\\"CitationRef\\\"\\u003e77\\u003c/span\\u003e\\u003c/sup\\u003e; summary statistics of the available evidence could not be calculated as not all reviews reported methodological details about the included studies. These limitations highlight the need for more standardized methodologies and reporting practices in future research.\\u003c/p\\u003e \\u003cp\\u003eNevertheless, our findings have important implications for policymakers and researchers. First, the large body of available evidence provides practical guidance for reducing the environmental footprint of healthcare in several well-identified emission hotspots, including surgical care, radiology, pharmaceuticals, patient and staff transport, and food waste:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eSurgery is highly resource-intensive: it uses three to six times more energy than other hospital wards \\u003csup\\u003e\\u003cspan citationid=\\\"CR78\\\" class=\\\"CitationRef\\\"\\u003e78\\u003c/span\\u003e\\u003c/sup\\u003e, accounts for 30% to 50% of hospital waste, including mostly single-use plastic products and packaging \\u003csup\\u003e\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR79\\\" class=\\\"CitationRef\\\"\\u003e79\\u003c/span\\u003e\\u003c/sup\\u003e, and represents up to 60% of total hospital emissions \\u003csup\\u003e\\u003cspan citationid=\\\"CR80\\\" class=\\\"CitationRef\\\"\\u003e80\\u003c/span\\u003e\\u003c/sup\\u003e. Reducing the use of high-emission anaesthetic gases, improving operating room energy management, optimising surgical pathways, and increasing the use of reusable instruments can make a substantial contribution to environmental sustainability \\u003csup\\u003e\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e,79 81\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003ePharmaceuticals account for about 25% of health system emissions \\u003csup\\u003e\\u003cspan citationid=\\\"CR82\\\" class=\\\"CitationRef\\\"\\u003e82\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR83\\\" class=\\\"CitationRef\\\"\\u003e83\\u003c/span\\u003e\\u003c/sup\\u003e, with certain medicines having a disproportionate impact. For example, inhalers generate about 3% of total NHS emissions in England. Key mitigation approaches include reducing pharmaceutical waste and selecting medicines with lower environmental impact, such as switching from metered-dose to dry-powder inhalers where clinically appropriate.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eClinical radiology and radiotherapy contribute about 10% of the healthcare carbon footprint \\u003csup\\u003e\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e\\u003c/sup\\u003e. The major drivers are energy-intensive equipment, large data storage needs, and waste from consumables, including radiological contrast agents \\u003csup\\u003e\\u003cspan citationid=\\\"CR84\\\" class=\\\"CitationRef\\\"\\u003e84\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR85\\\" class=\\\"CitationRef\\\"\\u003e85\\u003c/span\\u003e\\u003c/sup\\u003e. Existing evidence suggests that 40% to 91% of energy use occurs during idle time, when devices are switched on but not operating \\u003csup\\u003e\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e\\u003c/sup\\u003e. In addition, there is growing evidence on low-value diagnostic imaging \\u0026ndash; including, for example, MRI and CT scans which are unnecessarily performed \\u003csup\\u003e\\u003cspan citationid=\\\"CR86\\\" class=\\\"CitationRef\\\"\\u003e86\\u003c/span\\u003e\\u003c/sup\\u003e, thus the potential for emission reduction is substantial.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eFood waste represents approximately 20% to 30% of total hospital waste, with plate waste averaging around 30%-40% \\u003csup\\u003e87\\u003c/sup\\u003e, but varying depending on the type of ward. When decomposed in landfills, food waste emits methane which has a global warming potential 28 times greater than carbon dioxide \\u003csup\\u003e\\u003cspan citationid=\\\"CR88\\\" class=\\\"CitationRef\\\"\\u003e88\\u003c/span\\u003e\\u003c/sup\\u003e. Mitigation actions for food waste in hospitals cover all areas of the general food recovery hierarchy\\u003csup\\u003e\\u003cspan citationid=\\\"CR89\\\" class=\\\"CitationRef\\\"\\u003e89\\u003c/span\\u003e\\u003c/sup\\u003e, with prevention of waste generation as the most effective approach.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eTransport and travel account for 14% to 22% of healthcare emissions \\u003csup\\u003e\\u003cspan citationid=\\\"CR83\\\" class=\\\"CitationRef\\\"\\u003e83\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR90\\\" class=\\\"CitationRef\\\"\\u003e90\\u003c/span\\u003e\\u003c/sup\\u003e. Much of the existing mitigation evidence in this area focuses on telemedicine as an effective way to limit both patients and health professional transport.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eTo achieve system-wide impact, these insights need to be translated into formal policy instruments such as clinical guidelines, procurement standards, and organisational sustainability strategies. Some examples already exist, \\u003cem\\u003eThe Green Surgery Report\\u003c/em\\u003e \\u003csup\\u003e\\u003cspan citationid=\\\"CR91\\\" class=\\\"CitationRef\\\"\\u003e91\\u003c/span\\u003e\\u003c/sup\\u003e by the UK Health Alliance on Climate Change, \\u003cem\\u003eThe Greening the Operating Room and Perioperative Arena guidelines\\u003c/em\\u003e \\u003csup\\u003e\\u003cspan citationid=\\\"CR92\\\" class=\\\"CitationRef\\\"\\u003e92\\u003c/span\\u003e\\u003c/sup\\u003e by the American Society of Anaesthesiologists, and \\u003cem\\u003eIntensive Care Environmental Sustainability Recipe Book\\u003c/em\\u003e \\u003csup\\u003e\\u003cspan citationid=\\\"CR93\\\" class=\\\"CitationRef\\\"\\u003e93\\u003c/span\\u003e\\u003c/sup\\u003e by the Intensive Care Society.\\u003c/p\\u003e \\u003cp\\u003eSecond, the strong concentration of the literature on mitigation underlines the need for greater attention to climate adaptation in health systems. Climate change is already affecting health systems through heatwaves \\u003csup\\u003e\\u003cspan citationid=\\\"CR94\\\" class=\\\"CitationRef\\\"\\u003e94\\u003c/span\\u003e\\u003c/sup\\u003e, extreme weather events \\u003csup\\u003e\\u003cspan citationid=\\\"CR95\\\" class=\\\"CitationRef\\\"\\u003e95\\u003c/span\\u003e\\u003c/sup\\u003e, and changing disease patterns\\u003csup\\u003e\\u003cspan citationid=\\\"CR96\\\" class=\\\"CitationRef\\\"\\u003e96\\u003c/span\\u003e\\u003c/sup\\u003e, yet only a small number of systematic reviews addressed adaptation or resilience actions. While effective health system adaptation often requires coordination with other sectors\\u0026mdash;including urban planning, energy systems, and food systems \\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e \\u0026mdash;the limited number of rigorous systematic reviews that assess the quality or certainty of the underlying evidence on heat adaptation, climate-resilient infrastructure, or green resilience approaches within healthcare is notable. Strengthening the evidence base in this area is therefore an important priority for both research and policy.\\u003c/p\\u003e \\u003cp\\u003eThird, the evidence on environmental and economic co-benefits provides an important argument for policy action. Many mitigation strategies appear capable of simultaneously reducing greenhouse gas emissions and healthcare costs. In addition, emerging evidence \\u0026ndash; currently based on just a few reviews\\u003csup\\u003e\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e\\u003c/sup\\u003e \\u0026ndash; suggests that investigated mitigation actions have a neutral or maybe even positive impact on quality of care. For example, reviews by Eussen et al.\\u003csup\\u003e55\\u003c/sup\\u003e and Gumera et al.\\u003csup\\u003e56\\u003c/sup\\u003e showed that reusable medical instruments and reprocessed single use instruments (e.g., scissors, trocars, forceps, Veress needles) as well as reusable surgical headwear, offer significant environmental advantages and lower costs, while maintaining comparable performance and safety to disposable alternatives. Similarly, the review by Onasanya et al.\\u003csup\\u003e67\\u003c/sup\\u003e showed that switching to inhalers with much lower emissions was associated with improved inhaler adherence and asthma control. Consequently, policies that prioritise mitigation interventions may align climate objectives with broader health system goals, including cost containment and value-based care. Further research could usefully explore these co-benefits more systematically and examine the environmental implications of other cost-saving care strategies, such as shifting care to ambulatory settings and reducing low-value interventions. Existing efforts to incorporate environmental sustainability criteria (e.g. carbon emissions) in clinical trials \\u003csup\\u003e\\u003cspan citationid=\\\"CR97\\\" class=\\\"CitationRef\\\"\\u003e97\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR98\\\" class=\\\"CitationRef\\\"\\u003e98\\u003c/span\\u003e\\u003c/sup\\u003e, or health technology assessments\\u003csup\\u003e\\u003cspan citationid=\\\"CR99\\\" class=\\\"CitationRef\\\"\\u003e99\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR100\\\" class=\\\"CitationRef\\\"\\u003e100\\u003c/span\\u003e\\u003c/sup\\u003e and prioritising services that can provide the same health effect with lower environmental impact\\u003csup\\u003e\\u003cspan citationid=\\\"CR101\\\" class=\\\"CitationRef\\\"\\u003e101\\u003c/span\\u003e\\u003c/sup\\u003e are pointing in the right direction.\\u003c/p\\u003e \\u003cp\\u003eFourth, the environmental performance of specific interventions may vary considerably depending on local conditions such as energy sources, sterilization practices, reuse rates, or the organization of clinical pathways. For example, the relative environmental advantage of reusable vs. single-use medical instruments depends on a range of factors \\u003csup\\u003e\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e\\u003c/sup\\u003e, including the efficiency of sterilisation techniques (e.g., related to packing of autoclaves), the number of reuse cycles, and the proportion of renewable sources in the energy mix. Consequently, a similar mitigation action can be effective in one context and not in another. For example, the carbon footprint of reusable surgical instruments may be much higher in Australian settings (with mostly coal-based electricity) than in European ones (with a higher share of renewable energy sources) \\u003csup\\u003e\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e\\u003c/sup\\u003e. These findings suggest that policy guidance should combine general principles with context-specific assessments. Health systems may therefore benefit from integrating environmental impact evaluations into local decision-making processes, procurement strategies, and clinical pathway redesign.\\u003c/p\\u003e \\u003cp\\u003eFifth, our findings highlight the need to strengthen methodological standards and implementation capacity. The heterogeneity of environmental impact assessment methods across studies limits the comparability and synthesis of results. Wider use of standardized approaches \\u0026ndash; particularly LCAs \\u0026ndash; would improve the robustness of the evidence base. LCAs are based on dedicated ISO standards (ISO 14040\\u0026ndash;14044) \\u003csup\\u003e\\u003cspan citationid=\\\"CR76\\\" class=\\\"CitationRef\\\"\\u003e76\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR77\\\" class=\\\"CitationRef\\\"\\u003e77\\u003c/span\\u003e\\u003c/sup\\u003e and allow for a comprehensive product assessment, from \\u0026lsquo;cradle to grave\\u0026rsquo; (material extraction, production, use, and waste management). Furthermore, incorporating environmental impact indicators into standard health information and reporting systems would enable more systematic assessment of the environmental performance of healthcare activities, moving beyond the current reliance on ad hoc analyses conducted for individual studies.\\u003c/p\\u003e \\u003cp\\u003eFinally, translating evidence into practice will require stronger integration of climate and sustainability topics into health professional education, clinical training, and continuing professional development programs. We found two reviews underlining the crucial role of educational activities, training and skill development for climate mitigation and adaptation efforts \\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e\\u003c/sup\\u003e. However, current training programs often do not cover climate action topics \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR103\\\" citationid=\\\"CR102\\\" class=\\\"CitationRef\\\"\\u003e102\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR104\\\" class=\\\"CitationRef\\\"\\u003e104\\u003c/span\\u003e\\u003c/sup\\u003e. For example, in 2020 climate change topics were taught in only 15% of medical schools worldwide (survey by The International Federation of Medical Students Associations) \\u003csup\\u003e\\u003cspan citationid=\\\"CR102\\\" class=\\\"CitationRef\\\"\\u003e102\\u003c/span\\u003e\\u003c/sup\\u003e ; and surveys among intensive care professionals indicate that many lack formal training on environmentally sustainable practices \\u003csup\\u003e\\u003cspan citationid=\\\"CR105\\\" class=\\\"CitationRef\\\"\\u003e105\\u003c/span\\u003e\\u003c/sup\\u003e. Strengthening education and training in this area is therefore an important step toward enabling health professionals to incorporate environmentally sustainable practices into routine decision-making. At the same time, growing engagement among medical students and health professionals suggests increasing interest in this topic, providing a promising foundation for integrating climate and sustainability competencies into future health workforce training \\u003csup\\u003e\\u003cspan citationid=\\\"CR106\\\" class=\\\"CitationRef\\\"\\u003e106\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR107\\\" class=\\\"CitationRef\\\"\\u003e107\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e\"},{\"header\":\"5. CONCLUSIONS\",\"content\":\"\\u003cp\\u003eThis is the first umbrella review synthesizing systematic reviews on health system responses to climate change. It shows that a substantial and rapidly growing body of research exists on health system responses to climate change. The literature is strongly concentrated on mitigation strategies implemented at the level of individual providers \\u0026ndash; particularly in surgical care \\u0026ndash; while evidence on adaptation and climate resilience remains comparatively scarce. Across several areas, mitigation actions appear capable of generating environmental and economic co-benefits by simultaneously reducing greenhouse gas emissions and healthcare costs \\u0026ndash; and some evidence suggests that these benefits can be achieved without compromising quality of care. At the same time, some findings\\u0026mdash;such as those related to reusable instruments or specific surgical techniques\\u0026mdash;are highly context dependent.\\u003c/p\\u003e \\u003cp\\u003eThese findings have important implications for policymakers and researchers: First, the existing evidence base provides practical guidance for reducing environmental impacts in key emission hotspots, including surgical care, radiology, pharmaceuticals, transport, and food waste, which can be incorporated into clinical guidelines, procurement standards, and organisational strategies. Second, the strong focus on mitigation highlights the need to strengthen the evidence base on climate adaptation and health system resilience. Third, the potential for environmental and economic co-benefits provides a strong rationale for policy action. Fourth, the context dependence of several interventions suggests that general policy guidance should be complemented by local environmental impact assessments. Finally, strengthening methodological standards (particularly LCA), more routine collection of environmental data, and incorporation of climate topics in health workforce training could support more systematic and evidence-informed climate action in health systems.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003ch2\\u003eCompeting interest\\u003c/h2\\u003e \\u003cp\\u003eNone.\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eFunding\\u003c/h2\\u003e \\u003cp\\u003eNo dedicated funding.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eWHO. WHO guidance for climate resilient and environmentally sustainable health care facilities (2020) Accessed May 2, 2025. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.who.int/publications/i/item/9789240012226\\u003c/span\\u003e\\u003cspan address=\\\"https://www.who.int/publications/i/item/9789240012226\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWHO. Climate change (2023) Accessed May 2, 2025. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.who.int/news-room/fact-sheets/detail/climate-change-and-health\\u003c/span\\u003e\\u003cspan address=\\\"https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHealth and Climate Change. 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J Clim Change Health 11(10):100226. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.joclim.2023.100226\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.joclim.2023.100226\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHampshire K, Ndovu A, Bhambhvani H, Iverson N (2021) Perspectives on climate change in medical school curricula\\u0026mdash;A survey of U.S. medical students. J Clim Change Health 4(12):100033. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.joclim.2021.100033\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.joclim.2021.100033\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"climate change, health system, environmental sustainability, climate resilience, climate mitigation, climate adaptation\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9095097/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9095097/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eClimate change places increasing pressure on health systems. They must both reduce their negative impact on the environment and strengthen resilience to climate-related risks.\\u003c/p\\u003e\\u003ch2\\u003eObjective\\u003c/h2\\u003e \\u003cp\\u003eTo synthesize and map the evidence from systematic reviews on the scope and effectiveness of climate change mitigation and adaptation actions in health systems.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eAn umbrella review of systematic reviews examining health system responses to climate change was conducted. The review followed the Joanna Briggs Institute methodological guidelines and adhered to the PRISMA checklist. The included systematic reviews had to meet two overarching criteria: at least two databases were searched, and a predefined instrument was used to assess the quality or risk of bias of the included studies.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eThirty-nine systematic reviews published between 2020 and 2025 were included, covering 933 individual studies. Most reviews (35/39) focused exclusively on mitigation strategies, with evidence concentrated around major greenhouse gas emission hotspots: surgical procedures; radiology; pharmaceuticals; food waste; and transportation of patients and staff. Across these areas, many mitigation strategies were associated with environmental and economic co-benefits, although the underlying evidence was heterogeneous and often of low to moderate quality. In contrast, only a small number of reviews addressed climate adaptation and health system resilience.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eExisting evidence provides practical guidance on effective climate mitigation actions. The limited number of systematic reviews on climate adaptation highlights a gap in the evidence base. Translating mitigation evidence into clinical guidelines and policies and strengthening research on adaptation could support more systematic climate action in health systems.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Health systems’ responses to climate change: an umbrella review of systematic reviews\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-13 15:13:43\",\"doi\":\"10.21203/rs.3.rs-9095097/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"c64ca803-5a4f-4f36-80e7-809ea03d5d34\",\"owner\":[],\"postedDate\":\"March 13th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":64328918,\"name\":\"Health Policy\"},{\"id\":64328919,\"name\":\"Climatology\"},{\"id\":64328920,\"name\":\"Health Economics and Outcomes Research\"},{\"id\":64328921,\"name\":\"Environmental Policy\"}],\"tags\":[],\"updatedAt\":\"2026-03-13T15:13:43+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-13 15:13:43\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9095097\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9095097\",\"identity\":\"rs-9095097\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}