Not Enough to Meet a Growing Threat: A Scoping Review of Climate Adaptation and Intervention Strategies in Health Facilities across Low- and Middle- Income Countries

Not Enough to Meet a Growing Threat: A Scoping Review of Climate Adaptation and Intervention Strategies in Health Facilities across Low- and Middle- Income Countries | 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 Research Article Not Enough to Meet a Growing Threat: A Scoping Review of Climate Adaptation and Intervention Strategies in Health Facilities across Low- and Middle- Income Countries James Odhiambo Oguta, Britt Nakstad, Sharon Ochieng, Catherine Akoth, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8539861/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 is intensifying pressures on health systems, with facilities in low- and middle-income countries (LMICs) facing the greatest risks due to existing structural vulnerabilities. However, little is known about how these facilities are adapting or strengthening their resilience to climate-related shocks. This scoping review addresses this gap by synthesising documented climate-related adaptations and interventions in LMIC health facilities and assessing their alignment with the WHO 2023 Operational Framework for Climate-Resilient and Low-Carbon Health Systems. Methods Search terms were applied to MEDLINE, PubMed, Embase, Web of Science, Scopus, CINAHL and APA PsycINFO electronic databases, for articles published from inception to July 2025. Studies from LMICs, related to climate change and focused on health facility adaptations were included. Articles were extracted in Covidence software, and a narrative synthesis approach applied to identify key themes and patterns in the articles. Results In total, ten studies met the inclusion criteria. India contributed three studies, while Pakistan, Vietnam, Nepal, South Africa, Nigeria, Iran, and South Korea each contributed one. Our results reveal a narrow concentration of interventions across three domains (1) climate-smart health workforce development (2) climate-related emergency preparedness and management and (3) climate resilient infrastructure and technologies. Reported actions included simulation-based training, community-oriented education, ward relocation, ventilation and air-purification improvements, solar energy installations, water purification systems, and rapid spatial reconfigurations during floods. Although these interventions demonstrate efforts by facilities to maintain continuity of care under climate pressure, they remain small in scale, highly localised, and largely reactive. Several critical components of the WHO framework such as climate-transformative governance, sustainable financing, integrated risk monitoring and early warning systems, climate-informed health programmes, and climate and health research were entirely absent in the review. Barriers to adaptation included infrastructural vulnerability, weak governance, fragmented coordination, limited resources, workforce constraints, and behavioural challenges. Conclusion Climate related adaptations in LMIC health facilities remain limited, but available evidence shows that even small changes can strengthen resilience. Practical steps such as staff training, better infrastructure, stronger WASH systems, and clearer emergency procedures improve readiness and help keep care running during climate shocks. Yet major gaps remain, especially in long term evaluation and in the structural and governance weaknesses that limit sustained progress. Building a stronger evidence base and investing in facility resilience will be critical as climate risks continue to rise. Climate change health facilities adaptation intervention low- and middle-income countries Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Climate change has implications for global health, with low- and middle-income countries (LMICs) experiencing the worst impact [ 1 ]. Climate change has increased the number of extreme weather events (EWEs), including wildfires, droughts, heat waves, extreme cold events, typhoons, riverbank floods, and cyclones [ 2 , 3 ]. The EWEs are associated with an increased burden of diseases and changes that occur in their seasonal patterns [ 2 , 4 – 6 ]. This increase in the burden of diseases and their changes in seasonal patterns strains healthcare systems, especially in LMICs [ 5 ]. To address the health risks related to EWEs and climatic changes, health systems and facilities must prepare and adapt [ 5 ]. The World Health Organization (WHO) operational framework defines the key components that must be addressed to build climate-resilient health systems [ 7 ]. This framework includes financing, a health workforce, health service delivery, health information systems and essential medical products and technologies as its main components[ 7 ]. This framework is reflected in some of the strategies for preparation and adaptation to climate change employed by countries. However, different preparedness and adaptation strategies for healthcare systems to address climate change-related health risks have been utilized by various countries[ 8 , 9 ]. This includes adopting health policies and planning that incorporate climate change actions, engaging in promotion through community education and including climate change in school curricula, and ensuring disaster preparedness and response[ 8 ]. In addition, surveillance and monitoring for climate-sensitive diseases, improving health service delivery and mental health, establishing social support systems and equity, promoting research and capacity building for healthcare workers, health, sanitation, water and food, and health infrastructure supply chains are among the other strategies [ 8 – 10 ]. These preparedness and adaptation strategies are more advanced in high-income countries (HICs) than LMICs [ 7 ]. Some of the barriers to preparation and adaptation are inadequate resources, a lack of data, a poor policy landscape, and a lack of political will [ 8 , 10 ]. Moreover, most adaptation strategies are run by global health partners in these countries, which might fail to address local needs[ 7 , 8 ]. Few studies have examined how health facilities in low- and middle-income countries (LMICs) are adapting to and building resilience to climate change, resulting in important evidence gaps [ 11 , 12 ]. This scoping review aims to map and synthesise the existing literature on climate resilience and adaptation measures within healthcare facilities in LMICs. The review focuses on reported strategies related to workforce capacity, infrastructure adaptations, and emergency preparedness. By describing the scope, nature, and distribution of existing evidence, and by identifying gaps in the literature, this review seeks to inform future research, policy dialogue, and practice on strengthening climate-resilient health systems. Methods This scoping review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [ 13 ]. The review protocol was not pre-registered. Eligibility criteria The scoping review sought to include studies reporting health facility interventions and adaptation strategies targeted at strengthening facility resilience against climate-related health risks or mitigating the impacts of climate change. The studies must have been conducted within health facility settings involving either patients, health facility staff or any quality improvement interventions targeting any component of health facilities. As such, non-patient populations, outdoor workers or interventions targeting individuals living in communities were excluded unless it included those who accessed services at the respective facilities. In addition, we excluded studies that only evaluated the impacts of climate change without focusing on specific interventions applied. The review only included studies conducted in low- and middle-income countries as defined by the World Bank (Supplementary information 1: search Strategy) Information Sources Seven academic databases—MEDLINE, PubMed, Embase, Web of Science, Scopus, CINAHL and APA Psycinfo—were searched from inception. We also hand searched grey literature from Google Scholar, including the first 100 results. Only studies published in the English language were included in the review. Literature Search An iterative process was used to develop the search strategy for the review, which was initially piloted in MEDLINE in November 2024. The search strategy was formulated through a combination of the following key terms: “(Climate change OR synonyms) AND (Adaptation OR Mitigation OR synonyms) AND (Health Facilities OR Synonyms) AND (Low- and middle-income countries OR individual countries) The search strategy was developed in consultation with an information specialist, Mr. Khutsafalo Kadimo (KK), who is a librarian at the University of Botswana. The team met to review and approve the MEDLINE search strategy before its subsequent adaptation to the remaining academic databases. The initial search of the academic databases was conducted in November 2024 by KK and JOO, but later updated on July 19, 2025, by JOO. Study selection All the search results were uploaded to the Covidence platform, which aided automatic deduplication prior to the screening process. All titles and abstracts, and full texts were screened by two reviewers. JOO, VP, GM, JO and CA did the first round of title and abstract screening, while AL, JN, JP, ES, BN, SO, and MM performed the counter screening. Conflicts were resolved by a third reviewer from the team who was not involved in the initial review. Full-text screening was performed by SO, AL, JOO, BN, CA and ST. Data Extraction Data were extracted from the selected studies using an online Excel-based Google sheet. At first, the data extraction tool was developed by CA and JOO to capture the most important data points from the included studies. The team then met to review the draft tool and suggested various amendments before approving the tool for capturing the data from the included studies. The following are the key data points that were collected: Data collection from each study was conducted by at least two reviewers, with the first reviewer taking the lead in the first round of data collection, while the second reviewer performed the quality assessment. All data extraction was performed by JOO, AL, SO, BN, JP, FA, GM, CA, SKT, and VP. Additional quality assessment was performed by AL, SO and BN to ensure the completeness of all the data points. We did not assess the quality of the included studies due to their methodological heterogeneity. Data Synthesis A narrative synthesis, involving both quantitative and qualitative approaches, was employed to summarize and report the results from the selected studies following the methodological framework provided by Arksey and O’Malley [ 14 ]. We first performed numerical analyses to describe the characteristics of the included studies including their geographical distribution, study designs, study population and interventions. Thematic analysis was then used for in-depth synthesis of findings of the included studies allowing for cross-study comparisons. The results were reported using tables and figures and complemented with the narrative description of the key themes emerging from the synthesis. Results From an initial 6135 results retrieved from the literature searches, we included 10 studies [ 15 – 24 ] from eight LMICs. Figure 1 presents the PRISMA flow diagram describing the study selection process. Study Characteristics Figure 2 presents the characteristics of the included studies by country and continent, methodology, climate hazard studied, facility type and target population. There were two studies from India [ 23 , 24 ] and one was from Pakistan [ 20 ]. Two studies came from Southeast Asia, Vietnam [ 22 ] and Nepal [ 19 ]. Sub-Saharan Africa was represented by South Africa [ 16 ] and Nigeria [ 15 ]. One study originated in the Middle East, in Iran [ 18 ], and another in East Asia, in South Korea [ 21 ]. North America was represented by Haiti [ 17 ]. The studies drew on a wide range of methods. In South Africa and Nepal, Naidoo et al. (2022) and de Almeida et al. (2021) used interviews and documentary analysis. Minh et al. (2014) blended surveys, interviews, and focus groups to map how district and commune facilities in Vietnam adapt to storms and floods. A structured quantitative design [ 20 ] tested a heat-training programme through a multicentre pre–post study in Pakistani emergency departments, while Kakkad et al. (2014) analysed hospital records. Other quantitative studies, for example, Alok et al. (2025) in a Haitian clinic and Amadi et al. (2025) in Nigerian neonatal care examined clinical outcomes directly after interventions. Mishra et al. (2025) integrated facility-level indicators with staff interviews to explore resilience-building across India’s public health system. An et al. (2025) used experimental trials and Computational Fluid Dynamics (CFD) simulation to test air-purifier performance in a simulated Korean hospital ward. Two studies examined storms and flooding [ 16 , 22 ], and two focused on heat-related hazards [ 20 , 23 ]. Hurricanes shaped one study [ 17 ], while earthquakes featured across two others [ 19 , 24 ]. Air-quality risks were explored in studies on outdoor pollution [ 18 ] and indoor ventilation [ 21 ]. One study addressed high-carbon-footprint neonatal care [ 15 ]. The studies engaged a broad range of health facility types, including district and commune-level public health facilities [ 22 , 24 ], emergency departments [ 20 ]), neonatal and hospital wards [ 15 , 21 , 23 ], and teaching hospitals and prenatal clinics [ 18 , 19 ]. Target populations varied. Two studies centred on health managers and facility leaders [ 16 , 22 ], and three focused on frontline healthcare workers [ 19 , 20 , 24 ]. Neonates were the focus in two studies [ 15 , 23 ], pregnant women in one [ 18 ], and broader community groups in two [ 16 , 17 ]. One study involved immunocompromised hospital patients [ 21 ]. Application of the WHO Climate-Resilient Health System Framework Figure 3 presents the WHO conceptual framework for building climate-resilient health systems, which was used to guide the analytical lens for this review [ 25 ]. The framework outlines ten core components including leadership and governance; health workforce; climate and health risk and vulnerability assessment; integrated risk monitoring and early warning; health and climate research; climate-resilient and low-carbon health care facilities and technologies; management of environmental determinants of health; climate-informed health programmes; emergency preparedness and disaster risk management for health; and climate and health financing [ 25 ]. In the sections that follow, we first present the results of our synthesis (Table 1 and Supplementary Table 1) and then compare these findings against the WHO framework (Fig. 4 ) in the discussion section to identify areas of alignment, implementation, and remaining system level gaps. Climate-Related Adaptation Themes Across Studies Table 1 presents the main climate related adaptation themes identified from the review. Four overarching themes emerged: (1) capacity building; (2) structural adaptation and facility preparedness; (3) water, sanitation and hygiene (WASH) and emergency response beyond health facilities; and (4) barriers and challenges (Table 1 ). Table 1 Climate-Related Adaptation Themes Across Studies Theme Description of Intervention Examples From Literature Outcomes Reported Authors Capacity Building Strengthening staff skills in diagnosis, emergency response, treatment protocols and community education. Heat-emergency training; simulation drills; motivational interviewing; hygiene and water-safety education. Improved diagnosis; stronger emergency response; better treatment decisions; increased community preparedness. Khan 2023; Minh 2014; Araban 2017 Structural Adaptation and Facility Preparedness Physical and environmental changes to improve resilience, energy reliability, cooling and ventilation. Relocating neonatal wards; solar panels; reorganised hospital spaces; backup generators; optimised air purifiers. Reduced heat-related morbidity; improved thermal comfort; more reliable energy; stronger continuity of care. Kakkad 2014; Amadi 2025; Mishra 2025; de Almeida 2021; An 2025; Naidoo 2022 WASH and Emergency Response Beyond Facilities Improving water systems, sanitation, hygiene practices and community resilience; activating emergency response. RO systems; sanitation stations; disease surveillance; mobile outreach; temporary water supply; community meetings. Improved water safety; reduced contamination; better disease detection; maintained services during floods. Mishra 2025; Minh 2014; Naidoo 2022; Alok 2025 Barriers and Challenges Cross-cutting constraints including weak infrastructure, governance gaps, staffing shortages and limited resources. Damaged facilities; unclear emergency roles; weak early warning; insufficient staff; missing data; emotional strain. Reduced effectiveness of interventions; delayed response; inconsistent practice; difficulty maintaining care. Naidoo 2022; Minh 2014; Khan 2023; de Almeida 2021; Kakkad 2014; Alok 2025 1. Capacity Building for Climate Related Health Preparedness Our review found that capacity building interventions targeted both health workers and the communities they serve. Structured training programmes strengthened technical competencies and decision-making capacity for climate-related emergencies. In Vietnam, Minh et al. (2014) incorporated disaster simulation drills, first aid and emergency care training, and pre-season readiness activities that equipped health workers and village health teams for storm and flood events. Mishra et al. (2025) also reported training initiatives for staff and resident doctors to manage seasonal climate related surges, including those linked to storm-associated disease patterns. In Pakistan, Khan et al. (2023) demonstrated that the HEAT educational programme, which included workshops, simulation exercises, wall-mounted algorithms, and pocket-sized clinical manuals, improved diagnostic accuracy for heat-related conditions and increased the use of appropriate cooling techniques in emergency departments. Several interventions extended beyond health facilities to build preparedness at the community level. Minh et al. (2014) delivered education on hygiene, water safety, first aid, and storm-related risks, strengthening household preparedness and supporting more effective community responses during storms and floods. Araban et al. (2017) implemented a behavioural education programme for pregnant women that improved preventive behaviours and self-efficacy in reducing exposure to air pollution through motivational interviewing, educational materials, and daily SMS alerts. Mishra et al. (2025) introduced WASH-related behavioural supports, including sanitary stations and hygiene-promotion materials, which improved community water safety but were constrained by maintenance requirements and limited resources. Minh et al. (2014) additionally reported challenges in sustaining community engagement with water safety messaging. 2. Health Facility Preparedness, Structural Adaptation, and Low-Carbon System Resilience Our findings reveal that facilities are adopting combined infrastructural, technological, and energy-efficiency strategies to enhance climate resilience while reducing operational vulnerabilities. Five studies reported interventions aimed at strengthening facility preparedness and structural resilience to climate-related hazards, including heat, storms, pollution, and energy instability [ 16 , 17 , 21 , 23 , 24 ]. Facilities undertook spatial and infrastructural modifications to protect patients and ensure service continuity under extreme conditions. In India, Kakkad et al. (2014) demonstrated how relocating neonatal wards from the overheated fourth floor to the cooler ground floor reduced heat-related neonatal morbidity. In South Africa, Naidoo et al. (2022) highlighted rapid spatial and operational reconfigurations during flooding, enabling facilities to continue providing essential care despite environmental disruption. Alok et al. (2025) strengthened infrastructural capacity through extended operating hours, expanded staffing, and improvements to supply chains and outreach systems, supporting ongoing care in resource-limited, climate-sensitive settings. An (2025) showed how optimised air purifier placement within clinical wards reduced particulate exposure for vulnerable patients. Integrated within this broader structural adaptation agenda were sustainability and low-carbon initiatives aimed at improving energy security and reducing environmental impact. Mishra et al. (2025) reported installation of solar panels, energy-efficient lighting, and conservation practices alongside reverse-osmosis systems to ensure clean water, contributing to both resilience and reduced emissions, though implementation was limited by cost and maintenance requirements. Similarly, Amadi et al. (2025) demonstrated how a solar-powered neonatal device expanded access to essential care in remote, off-grid settings. 3. WASH Improvements and Emergency Response Measures beyond Health facilities Although the primary focus of this review was on facility-level interventions, we found that several facilities implemented actions that extended beyond the facilities into the communities they serve. For example, Minh et al. (2014) delivered ongoing community education on hygiene, water safety, first aid, and storm-related risks, which helped strengthen household preparedness and supported more effective community-level response during storms and floods. Similarly, Araban et al. (2017) implemented a behavioural education programme for pregnant women including motivational interviewing, educational materials, and daily SMS alerts which improved preventive behaviours and self-efficacy in reducing exposure to air pollution. Interventions related to water and sanitation resilience were reported in two studies. Mishra et al. (2025) described the installation of reverse-osmosis systems, sanitary stations, and WASH-related behavioural supports, which improved water safety but were constrained by maintenance demands and limited resources. Minh et al. (2014) implemented community-oriented water safety activities, including hygiene education and preparedness messaging, which helped reduce contamination risks during storms and floods, however community outreach was challenged. Emergency preparedness and disaster response measures were identified in four studies. Besides strengthened WASH system, Mishra et al. (2025) highlighted essential medicine stocks, and staff training and. Minh et al. (2014) reported structured pre-season planning, disaster simulation drills, and emergency kit stocking that enhanced storm and flood readiness. Naidoo et al. (2022) documented rapid operational adjustments during flooding, including staff redeployment, extended service hours, and mobile outreach to maintain essential care. De Almeida et al. (2021) described activation of a hospital disaster plan that facilitated coordinated task-sharing, flexible staff deployment, and prioritisation of emergency services during a surge in trauma cases. 4. Barriers and challenges The review found that structural and systems level barriers such as damaged infrastructure, unreliable power, and inadequate WASH and ventilation systems disrupted service delivery in South Africa [ 16 ], Vietnam [ 22 ], and Nepal [ 19 ]. In India, neonatal wards located on the hottest floor exacerbated heat vulnerability before relocation [ 23 ], while older hospital buildings in Korea reduced the efficacy of air-purification interventions [ 21 ]. Weak governance and planning such as the absence of early warning systems, unclear roles, fragmented coordination, and insufficient funding constrained preparedness across South Africa, Vietnam, and India [ 16 , 22 , 24 ]. Resource shortages, including a lack of supplies, inconsistent stock, and limited equipment, were commonly reported, with financial constraints preventing expanded trials of climate-responsive technologies in Nigeria [ 15 ]. The review also established that the workforce, behavioural, and contextual barriers shaped the uptake of climate adaptation measures. Several studies reported insufficient training, uneven staff capacity, and heavy workloads as impediments to implementing emergency practices, particularly in Pakistan’s emergency departments [ 20 ] and in Vietnam’s primary care system [ 22 ]. Emotional stress and staff fatigue further constrained response efforts during the Nepal earthquake [ 19 ]. At the community level, behavioural recommendations sometimes conflicted with daily responsibilities, limiting adherence among pregnant women in Iran [ 18 ]. In Haiti and India, incomplete clinical data and lack of disease coding hindered accurate assessment of climate-sensitive conditions [ 17 , 23 ]. Discussion This scoping review examined what climate-related interventions and adaptations are taking place within health facilities in low- and middle-income countries. Our findings show that some facilities are already responding to climate pressures through training initiatives, structural modifications, emergency preparedness measures, WASH improvements, and low-carbon technologies. Capacity building Across the studies in this review, capacity building was one of the clearest pathways to improving readiness for climate related health risks. Training and simple clinical tools helped staff respond more effectively during extreme events. In Pakistan, training improved how emergency providers recognised and managed heat emergencies [ 20 ]. In Vietnam, preparedness exercises and clearer guidance strengthened coordination and early response [ 22 ]. Staff in Nepal also reported that shared roles, flexible decision making, and prior drills helped them cope during the earthquake response [ 19 ]. These examples show that even minimal training efforts can shift confidence, decision making, and the organisation of care inside health facilities. Evidence from high income countries supports this pattern. For example, after the 2003 heatwave in France, national heat preparedness activities that included seasonal training and clearer clinical protocols were introduced [ 26 , 27 ]. A later heatwave in 2006 caused far fewer deaths, partly because professionals were more aware and better prepared [ 28 ]. In England, on the other hand, the Heatwave Plan requires hospitals, general practice teams, and community services to train staff ahead of each summer season [ 29 ]. Structural adaptations identified in this review reflect patterns already documented in high income countries (HIC) where infrastructure resilience is seen as central to clinical preparedness. Investments in building upgrades, protected power systems, improved ventilation, and strengthened water infrastructure to maintain safe conditions during heatwaves, storms, and floods [ 30 – 32 ]. These developments help contextualise the LMIC findings. Even modest changes such as cooler clinical spaces, reliable generators, or a more stable water supply supported continuity of care during climate pressures. Evidence from HIC also shows that resilient health facilities, diversified energy and water sources can reduce service disruptions and protect vulnerable patients [ 33 ]. The structural adaptations emerging in LMIC facilities, though often achieved with limited resources, are aligned with global best practice. The WASH and community preparednes s measures identified in this review echo wider evidence from high income settings, where strengthened water systems, hygiene protocols, and community outreach form core elements of climate resilience. Studies from Europe and North America show that hospitals and public health authorities increasingly pair facility level WASH improvements with broader emergency coordination, including early warning systems, community risk communication, and cross-sector planning during floods, storms, and heat events [ 31 , 33 ]. These models help contextualise the LMIC findings as seen in Vietnam, where pre-season planning, expanded hygiene education, and strengthened disease surveillance improved local readiness for flood related surges [ 22 ]. In India, investments in water treatment systems, sanitation stations, and waste segregation supported safer service delivery during seasonal climate-related pressures [ 24 ]. In Haiti, community outreach, vaccination drives, and hygiene promotion helped sustain routine care and reduce infections in areas experiencing environmental stress [ 17 ]. Similar approaches in high income settings, such as integrated water safety plans, joint emergency command centres, and coordinated risk communication show that WASH resilience and community engagement are the most effective interventions in adverse events. Overall, structural weaknesses, limited resources, and unclear emergency systems constrained the effectiveness of climate-related interventions across the health facilities. Workforce shortages, inadequate training, and high patient loads further reduced the ability of staff to respond consistently during climate pressures. These barriers mirror challenges seen in high income settings. Alignment with WHO Climate-Resilient Health System Framework Figure 4 presents how the included studies in this review align with the pillars of the WHO framework, highlighting the gaps in evidence across dimensions. As illustrated in the results and Fig. 4 , most documented interventions cluster around three domains: climate-smart health workforce development [ 20 , 22 , 24 ], climate-related emergency preparedness and management [ 16 , 19 , 22 , 24 ], and climate-resilient infrastructure and technologies [ 15 , 16 , 21 , 23 , 24 ]. While these interventions demonstrate efforts to strengthen resilience under worsening climate pressures, they remain highly localised, small in scale, and poorly integrated into broader system planning. Overall, the ten studies from the review shows minimal implementation of climate-resilience measures across LMIC health facilities, with adaptations tending to be reactive and facility-specific rather than embedded within coordinated, system-wide strategies. Equally striking are the components of the WHO framework that were entirely absent. No studies addressed climate-transformative governance, sustainable climate and health financing, integrated risk monitoring or early warning systems, climate-informed health programmes, or climate and health research domains critical for long term system resilience. These omissions, coupled with structural vulnerabilities, weak governance, fragmented coordination, resource shortages, limited staff capacity, and behavioural constraints, reveal some of the systemic barriers limiting adaptation. The findings suggest that LMIC health facilities remain far from operationalising the WHO framework and highlight the need for strengthened governance, dedicated financing, integrated surveillance and early-warning capacities, and the routine incorporation of climate considerations into health system planning and service delivery. Strengths and limitations This scoping review provides one of the first systematic examinations of climate related interventions and adaptations within health facilities in low and middle-income countries. Incorporating qualitative, quantitative, and mixed-methods studies from diverse settings, offered a comprehensive view of how facilities are responding to climate pressures in routine practice. The thematic synthesis covering capacity building, structural adaptation, WASH improvements, and system barriers provides a clear framework for interpreting heterogeneous evidence. The review also identifies important gaps in knowledge, helping to shape priorities for future research on climate resilience in health facilities. This review is shaped by several limitations. The evidence on climate related adaptations in LMIC health facilities is still sparse and uneven, with many studies describing small, context specific interventions and offering limited outcomes or follow up. Inconsistent reporting, particularly on indoor conditions, resource constraints and implementation processes, reduced comparability across settings. Relevant studies may also have been missed because climate and health systems research is poorly indexed, especially in grey literature. Finally, as a scoping review, we did not appraise study quality, which limits the strength of any causal interpretations. Conclusion Climate related adaptations and interventions in LMIC health facilities remain narrow, uneven, and reactive. While pockets of innovation exist, they touch only a fraction of the components outlined in the WHO 2023 framework. Our review shows that even small-scale interventions can bolster preparedness, yet system-wide resilience remains out of reach without stronger governance, sustained financing, robust surveillance, and investment in infrastructure and workforce capacity. As climate pressures intensify, expanding the evidence base and embedding climate readiness into the core of health system planning will be important if facilities are to move beyond improvised responses toward genuine climate resilience. Declarations Competing interests The authors have no competing interests. Funding The authors received no funding for this review. JOO and CA are funded by Wellcome Trust as part of a doctoral training grant [218462/Z/19/Z] to pursue PhD in Public Health Economics and Decision Science at the University of Sheffield. Author Contribution AL, BN, JOO and SO conceived the study, led the design, and contributed to data extraction, data cleaning, writing and manuscript review. JOO conducted the literature search. JOO, CA, and ST contributed to data screening, data extraction, drafting of the manuscript and review. GM, VP, MM and JP contributed to data screening, extraction and review of the manuscript. JOO and CA performed the data wrangling, manipulation and visualisation to generate the study figures. All authors critically read, reviewed and approved the final manuscript for publication. Acknowledgement We would like to acknowledge Evelyne Shu and Julian Natukunda for their assistance with data extraction, and the University of Botswana librarian, Mr. Khutsafalo Kadimo, for supporting the literature search. Availability of data and materials The review draws exclusively on publicly accessible literature; therefore, all data are available within the sources cited, and no new datasets were produced by the authors. The R code for reproducing Fig. 1 is stored on this Github repository ( https://github.com/mcogutajamo/Climate_Adap_Review ). References St Louis ME, Hess JJ. Climate change: impacts on and implications for global health. Am J Prev Med. 2008;35:527–38. Weilnhammer V, Schmid J, Mittermeier I, Schreiber F, Jiang L, Pastuhovic V, et al. Extreme weather events in europe and their health consequences - A systematic review. Int J Hyg Environ Health. 2021;233:113688. Patwary MM, Bardhan M, Haque MA, Moniruzzaman S, Gustavsson J, Khan MMH, et al. Impact of extreme weather events on mental health in South and Southeast Asia: A two decades of systematic review of observational studies. Environ Res. 2024;250:118436. Pardon MK, Dimmock J, Chande R, Kondracki A, Reddick B, Davis A, et al. Mental health impacts of climate change and extreme weather events on mothers. Eur J Psychotraumatol. 2024;15:2296818. Ebi KL, Vanos J, Baldwin JW, Bell JE, Hondula DM, Errett NA, et al. Extreme weather and climate change: Population health and health system implications. Annu Rev Public Health. 2021;42:293–315. Ryan SJ, Ebi K, Welburn S, Singer B, editors. Addressing vulnerability, building resilience: community-based adaptation to vectorborne diseases in the context of global change Kevin Louis Bardosh1,2. Sadie J. Ebi KL, Berry P, Campbell-Lendrum D, Cissé G, Hess J, Ogden N, et al. Health System Adaptation to Climate Variability and Change. Washington, DC; 2019. Ansah EW, Amoadu M, Obeng P, Sarfo JO. Health systems response to climate change adaptation: a scoping review of global evidence. BMC Public Health. 2024;24:2015. Kulkarni MA, Duguay C, Ost K. Charting the evidence for climate change impacts on the global spread of malaria and dengue and adaptive responses: a scoping review of reviews. Global Health. 2022;18:1. Meyer R, Wright C, Rother H-A. Assessment of SADC countries’ national adaptation planning health impacts inclusion: A thorough review. Ann Glob Health. 2024;90:57. Naser K, Haq Z, Naughton BD. The impact of climate change on health services in low- and middle-income countries: A systematised review and thematic analysis. Int J Environ Res Public Health. 2024;21:434. Nayna Schwerdtle P, Ngo TA, Hasch F, Phan TV, Quitmann C, Montenegro-Quiñonez CA. Climate change resilient health facilities: a scoping review of case studies in low and middle-income countries. Environ Res Lett. 2024;19:074041. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for Scoping Reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169:467–73. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19–32. Amadi H, Muoneke L-SC, Meremikwu MM, Udo JJ, Jimoh A, Ochigbo SO, et al. New solar-powered device for the treatment of neonatal hyperbilirubinaemia in hardest-to-reach places tested in Nigeria. BMJ Innov. 2025;11:56–63. Naidoo K, Manyangadze T, Lokotola CL. Primary care disaster management for extreme weather events, South Africa. Afr J Prim Health Care Fam Med. 2022;14:e1–2. Alok A, Bakhit M, Helne D, Milord P, Socrate M, Clermont C, et al. Updating a rural clinic in tiburón, Haiti. HCA Healthc J Med. 2025;6:51–6. Araban M, Tavafian SS, Zarandi SM, Hidarnia AR, Burri A, Montazeri A. A behavioral strategy to minimize air pollution exposure in pregnant women: a randomized controlled trial. Environ Health Prev Med. 2017;22:26. Moitinho de Almeida M, van Loenhout JAF, Singh Thapa S, Kumar KC, Prakash Mahara D, Guha-Sapir D, et al. Hospital resilience after the 2015 earthquake in Nepal: Results from semi-structured interviews with hospital staff. Front Public Health. 2021;9. https://doi.org/10.3389/fpubh.2021.602509 . Khan NU, Khan UR, Ahmed N, Ali A, Raheem A, Soomar SM, et al. Improvement in the diagnosis and practices of emergency healthcare providers for heat emergencies after HEAT (heat emergency awareness & treatment) an educational intervention: a multicenter quasi-experimental study. BMC Emerg Med. 2023;23:12. An IH, Kwak DB, Lee J, Park SH, Yook SJ. Optimal operating positions of two air purifiers for improving indoor air quality in hospital wards. J Hosp Infect. 2025;159:42–51. Van Minh H, Anh TT, Rocklöv J, Giang KB, Trang LQ, Sahlen K-G, et al. Primary healthcare system capacities for responding to storm and flood-related health problems: a case study from a rural district in central Vietnam. Glob Health Action. 2014;7. https://doi.org/10.3402/gha.v7.23007 . Kakkad K, Barzaga ML, Wallenstein S, Azhar GS, Sheffield PE. Neonates in Ahmedabad, India, during the 2010 heat wave: a climate change adaptation study. J Environ Public Health. 2014;2014:946875. Mishra S, Verma P, Patidar N, Katira JM, Gaonkar N, Solanki J, et al. Building climate resilient healthcare systems through interventions in Gujarat India. Discov Public Health. 2025;22. https://doi.org/10.1186/s12982-025-00659-7 . World Health Organization. Operational framework for building climate resilient and low carbon health systems. Genève, Switzerland: World Health Organization; 2023. Pascal M, Laaidi K, Ledrans M, Baffert E, Caserio-Schönemann C, Le Tertre A, et al. France’s heat health watch warning system. Int J Biometeorol. 2006;50:144–53. Hémon D, Jougla E. The 2003 heat wave in France. Revue d’Épidémiologie et de Santé Publique. Journal of Epidemiology & Community Health. 2003;62:227–38. Fouillet A, Rey G, Wagner V, Laaidi K, Empereur-Bissonnet P, Le Tertre A, et al. Has the impact of heat waves on mortality changed in France since the European heat wave of summer 2003? A study of the 2006 heat wave. Int J Epidemiol. 2008;37:309–17. NHS. heatwave PLAN FOR ENGLAND: PROTECTING HEALTH AND REDUCING HARM FROM EXTREME HEAT AND HEATWAVES. 2011. Elstow K. Tracking climate adaptation in hospitals: An inventory of structural measures to adapt the external, internal and systems assets of hospitals to anticipated climate changes. Sustainable Cities and Society; 2024. Paterson J, Berry P, Ebi K, Varangu L. Health care facilities resilient to climate change impacts. Int J Environ Res Public Health. 2014;11:13097–116. Seltenrich N. Safe from the storm: Creating climate-resilient health care facilities. Environ Health Perspect. 2018;126:102001. Hcwh E. Practical guide for building climate-resilient health systems. 2024. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1Studiesincludedinthereview.ods SupplementaryMaterialSearchStrategy.pdf 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-8539861","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570742200,"identity":"7e2bf32f-2d3e-4f98-a752-de768a08b33d","order_by":0,"name":"James Odhiambo Oguta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYBADZiBmfAAkePiI05AA1sJsANLCRqwWEGCTAJOEFOu2Hz78mveHHTv/tMPHKr/m2MmwMTA/fHQDjxazM2lp1jwJycwSt9PSbstuSwY6jM3YOAeflhs8ZsY8CczMDLdzzG5LbmMGauFhkyZCSz2zPFBLseS2eqK0GD/mSTjMbADUwvhx22EitAD9wjgn7Tiz4e20ZGnGbcd52JgJ+eX44cMf3thUJ8vdTj748ee2ant+9uaHj/FpYYBGRzKIxcwDJvErByv5ACTsQCzGH4RVj4JRMApGwQgEAGFsQgm9Gew6AAAAAElFTkSuQmCC","orcid":"","institution":"University of Sheffield","correspondingAuthor":true,"prefix":"","firstName":"James","middleName":"Odhiambo","lastName":"Oguta","suffix":""},{"id":570742201,"identity":"62827832-8cba-4d9f-ab1a-857a06c89f21","order_by":1,"name":"Britt Nakstad","email":"","orcid":"","institution":"University of Botswana","correspondingAuthor":false,"prefix":"","firstName":"Britt","middleName":"","lastName":"Nakstad","suffix":""},{"id":570742210,"identity":"94a2eb78-4215-45cf-88bd-ecf4f67ec824","order_by":2,"name":"Sharon Ochieng","email":"","orcid":"","institution":"NextGen For Earth","correspondingAuthor":false,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Ochieng","suffix":""},{"id":570742211,"identity":"a87398cc-8517-4b34-b66a-01a69caa57d1","order_by":3,"name":"Catherine Akoth","email":"","orcid":"","institution":"University of Sheffield","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Akoth","suffix":""},{"id":570742212,"identity":"fb9f4389-7546-4e7d-884d-ca096fcbff61","order_by":4,"name":"Solomon Kimutai Toweet","email":"","orcid":"","institution":"Moi University","correspondingAuthor":false,"prefix":"","firstName":"Solomon","middleName":"Kimutai","lastName":"Toweet","suffix":""},{"id":570742213,"identity":"6904b531-9d89-4438-9db5-b2cf86351284","order_by":5,"name":"Jessie Pinchoff","email":"","orcid":"","institution":"Independent Consultant","correspondingAuthor":false,"prefix":"","firstName":"Jessie","middleName":"","lastName":"Pinchoff","suffix":""},{"id":570742215,"identity":"6934615e-baad-4385-9f60-6c0cb92a5c31","order_by":6,"name":"Gulnaz Mohamoud","email":"","orcid":"","institution":"Aga Khan University hospital","correspondingAuthor":false,"prefix":"","firstName":"Gulnaz","middleName":"","lastName":"Mohamoud","suffix":""},{"id":570742217,"identity":"ccd4a049-e88f-4569-9322-91e0d8c8990e","order_by":7,"name":"Josphat Martin Muchangi","email":"","orcid":"","institution":"AMREF International University","correspondingAuthor":false,"prefix":"","firstName":"Josphat","middleName":"Martin","lastName":"Muchangi","suffix":""},{"id":570742219,"identity":"5cdebf20-f673-4a0a-9212-ce49b18078da","order_by":8,"name":"Vincent Pagiwa","email":"","orcid":"","institution":"University of Botswana","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"Pagiwa","suffix":""},{"id":570742222,"identity":"931c8da3-c3d1-4c64-bb7c-8ce0b3627903","order_by":9,"name":"Adelaide Lusambili","email":"","orcid":"","institution":"NextGen For Earth","correspondingAuthor":false,"prefix":"","firstName":"Adelaide","middleName":"","lastName":"Lusambili","suffix":""}],"badges":[],"createdAt":"2026-01-07 10:08:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8539861/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8539861/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100356910,"identity":"56bfa723-0a38-48cc-9299-d412069731d6","added_by":"auto","created_at":"2026-01-16 07:17:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5967752,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptFileClimateAdaptationFinal.docx","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/b96b382ebb96f257957a4aa9.docx"},{"id":99823607,"identity":"57db8149-850d-4c47-b519-e15fa11256a7","added_by":"auto","created_at":"2026-01-08 15:51:44","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12304,"visible":true,"origin":"","legend":"","description":"","filename":"3e0ebc6cddea4021ae46e47b49477ae9.json","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/05d0b0b03b6c555d9ad7613a.json"},{"id":100356634,"identity":"2ea49f0e-274a-4b43-97f7-805205f54700","added_by":"auto","created_at":"2026-01-16 07:16:14","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":169261,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialSearchStrategy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/b6505de98fb279bcec03c6c6.pdf"},{"id":100356300,"identity":"7b72ffaa-1b40-4058-b04c-cd94575b2eae","added_by":"auto","created_at":"2026-01-16 07:01:23","extension":"ods","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":17598,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1Studiesincludedinthereview.ods","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/5fdeefb61413ef9f88872b86.ods"},{"id":100356749,"identity":"ab7938f7-d86c-4317-8947-4b1ab43ef12a","added_by":"auto","created_at":"2026-01-16 07:17:17","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":102127,"visible":true,"origin":"","legend":"","description":"","filename":"3e0ebc6cddea4021ae46e47b49477ae91enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/c3b89a4189435cfd311281a4.xml"},{"id":99823623,"identity":"55ca493c-7ea5-4572-8157-0bb8eed17f7f","added_by":"auto","created_at":"2026-01-08 15:51:46","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":21787,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/5b46c056475be515068f2195.png"},{"id":99823616,"identity":"bd2df373-15af-4bba-a683-cc95014e1d0b","added_by":"auto","created_at":"2026-01-08 15:51:46","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":64104,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/ddba167491c3aaaa2549c867.png"},{"id":100356659,"identity":"9ff4b41d-2b45-4ef2-801a-5a78b2b08156","added_by":"auto","created_at":"2026-01-16 07:16:26","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":174254,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/7e055a952149a4533bd84fa7.png"},{"id":100356434,"identity":"fbb3d8da-ae7c-4893-ba23-1285e301758d","added_by":"auto","created_at":"2026-01-16 07:09:15","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116492,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/8750b6d5c739d5547b9f39b1.png"},{"id":99823618,"identity":"c65ed651-07f5-43a4-89dd-73f5e9d39556","added_by":"auto","created_at":"2026-01-08 15:51:46","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101232,"visible":true,"origin":"","legend":"","description":"","filename":"3e0ebc6cddea4021ae46e47b49477ae91structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/f01ebdb1d3a8415992bc9338.xml"},{"id":99823621,"identity":"2adc05f5-c5f3-43c0-8c76-bff126792052","added_by":"auto","created_at":"2026-01-08 15:51:46","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":114077,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/803c9834a277d90ceb729f92.html"},{"id":100356503,"identity":"0b746062-2958-487d-83f1-dbd9d831961b","added_by":"auto","created_at":"2026-01-16 07:13:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":51201,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Diagram\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/6fe5cbc058640e12aaff3ce1.png"},{"id":100356944,"identity":"b26293a1-f8c7-4143-920b-0ddf51574c02","added_by":"auto","created_at":"2026-01-16 07:18:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":309188,"visible":true,"origin":"","legend":"\u003cp\u003eCharacteristics of the included studies\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/d4688604569d7ba2b7c724e8.png"},{"id":100356430,"identity":"5deb3b80-39e2-4c61-a326-c1b755785111","added_by":"auto","created_at":"2026-01-16 07:09:09","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":663015,"visible":true,"origin":"","legend":"\u003cp\u003eWHO Operational Framework for Building Climate Resilient Health Systems\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/0b0987131f07be22c2ab5880.jpeg"},{"id":99823620,"identity":"e9e2cf04-4cfa-46c6-b812-e158f8c81572","added_by":"auto","created_at":"2026-01-08 15:51:46","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":830616,"visible":true,"origin":"","legend":"\u003cp\u003eAlignment of the included studies with the WHO Operational Framework for Building Climate Resilient Health Systems\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/b776d5be8c619e1f8bd14b00.png"},{"id":101942682,"identity":"c0df6e7b-9788-42d9-a1fb-6f8efa61af0c","added_by":"auto","created_at":"2026-02-05 09:33:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2688179,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/44b7ae38-d57d-49ed-a789-ab3a1fb9b2a1.pdf"},{"id":100356657,"identity":"3674428e-76b4-4f21-bd2c-bb607312db93","added_by":"auto","created_at":"2026-01-16 07:16:25","extension":"ods","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17598,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1Studiesincludedinthereview.ods","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/100414c9d1e104d8874ecfa3.ods"},{"id":100356855,"identity":"617a24f2-10e6-4488-bb99-dcaf2a641ca4","added_by":"auto","created_at":"2026-01-16 07:17:48","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":169261,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialSearchStrategy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8539861/v1/23959951e8a5313704ca208f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Not Enough to Meet a Growing Threat: A Scoping Review of Climate Adaptation and Intervention Strategies in Health Facilities across Low- and Middle- Income Countries","fulltext":[{"header":"Background","content":"\u003cp\u003eClimate change has implications for global health, with low- and middle-income countries (LMICs) experiencing the worst impact [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Climate change has increased the number of extreme weather events (EWEs), including wildfires, droughts, heat waves, extreme cold events, typhoons, riverbank floods, and cyclones [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The EWEs are associated with an increased burden of diseases and changes that occur in their seasonal patterns [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This increase in the burden of diseases and their changes in seasonal patterns strains healthcare systems, especially in LMICs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To address the health risks related to EWEs and climatic changes, health systems and facilities must prepare and adapt [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The World Health Organization (WHO) operational framework defines the key components that must be addressed to build climate-resilient health systems [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This framework includes financing, a health workforce, health service delivery, health information systems and essential medical products and technologies as its main components[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This framework is reflected in some of the strategies for preparation and adaptation to climate change employed by countries.\u003c/p\u003e \u003cp\u003eHowever, different preparedness and adaptation strategies for healthcare systems to address climate change-related health risks have been utilized by various countries[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This includes adopting health policies and planning that incorporate climate change actions, engaging in promotion through community education and including climate change in school curricula, and ensuring disaster preparedness and response[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition, surveillance and monitoring for climate-sensitive diseases, improving health service delivery and mental health, establishing social support systems and equity, promoting research and capacity building for healthcare workers, health, sanitation, water and food, and health infrastructure supply chains are among the other strategies [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These preparedness and adaptation strategies are more advanced in high-income countries (HICs) than LMICs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Some of the barriers to preparation and adaptation are inadequate resources, a lack of data, a poor policy landscape, and a lack of political will [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Moreover, most adaptation strategies are run by global health partners in these countries, which might fail to address local needs[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Few studies have examined how health facilities in low- and middle-income countries (LMICs) are adapting to and building resilience to climate change, resulting in important evidence gaps [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis scoping review aims to map and synthesise the existing literature on climate resilience and adaptation measures within healthcare facilities in LMICs. The review focuses on reported strategies related to workforce capacity, infrastructure adaptations, and emergency preparedness. By describing the scope, nature, and distribution of existing evidence, and by identifying gaps in the literature, this review seeks to inform future research, policy dialogue, and practice on strengthening climate-resilient health systems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis scoping review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The review protocol was not pre-registered.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria\u003c/h2\u003e \u003cp\u003eThe scoping review sought to include studies reporting health facility interventions and adaptation strategies targeted at strengthening facility resilience against climate-related health risks or mitigating the impacts of climate change. The studies must have been conducted within health facility settings involving either patients, health facility staff or any quality improvement interventions targeting any component of health facilities. As such, non-patient populations, outdoor workers or interventions targeting individuals living in communities were excluded unless it included those who accessed services at the respective facilities. In addition, we excluded studies that only evaluated the impacts of climate change without focusing on specific interventions applied. The review only included studies conducted in low- and middle-income countries as defined by the World Bank (Supplementary information 1: search Strategy)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInformation Sources\u003c/h3\u003e\n\u003cp\u003eSeven academic databases\u0026mdash;MEDLINE, PubMed, Embase, Web of Science, Scopus, CINAHL and APA Psycinfo\u0026mdash;were searched from inception. We also hand searched grey literature from Google Scholar, including the first 100 results. Only studies published in the English language were included in the review.\u003c/p\u003e\n\u003ch3\u003eLiterature Search\u003c/h3\u003e\n\u003cp\u003eAn iterative process was used to develop the search strategy for the review, which was initially piloted in MEDLINE in November 2024. The search strategy was formulated through a combination of the following key terms:\u003c/p\u003e \u003cp\u003e\u0026ldquo;(Climate change OR synonyms) AND (Adaptation OR Mitigation OR synonyms) AND (Health Facilities OR Synonyms) AND (Low- and middle-income countries OR individual countries)\u003c/p\u003e \u003cp\u003eThe search strategy was developed in consultation with an information specialist, Mr. Khutsafalo Kadimo (KK), who is a librarian at the University of Botswana. The team met to review and approve the MEDLINE search strategy before its subsequent adaptation to the remaining academic databases. The initial search of the academic databases was conducted in November 2024 by KK and JOO, but later updated on July 19, 2025, by JOO.\u003c/p\u003e\n\u003ch3\u003eStudy selection\u003c/h3\u003e\n\u003cp\u003eAll the search results were uploaded to the Covidence platform, which aided automatic deduplication prior to the screening process. All titles and abstracts, and full texts were screened by two reviewers. JOO, VP, GM, JO and CA did the first round of title and abstract screening, while AL, JN, JP, ES, BN, SO, and MM performed the counter screening. Conflicts were resolved by a third reviewer from the team who was not involved in the initial review. Full-text screening was performed by SO, AL, JOO, BN, CA and ST.\u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eData were extracted from the selected studies using an online Excel-based Google sheet. At first, the data extraction tool was developed by CA and JOO to capture the most important data points from the included studies. The team then met to review the draft tool and suggested various amendments before approving the tool for capturing the data from the included studies. The following are the key data points that were collected:\u003c/p\u003e \u003cp\u003eData collection from each study was conducted by at least two reviewers, with the first reviewer taking the lead in the first round of data collection, while the second reviewer performed the quality assessment. All data extraction was performed by JOO, AL, SO, BN, JP, FA, GM, CA, SKT, and VP. Additional quality assessment was performed by AL, SO and BN to ensure the completeness of all the data points. We did not assess the quality of the included studies due to their methodological heterogeneity.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Synthesis\u003c/h2\u003e \u003cp\u003eA narrative synthesis, involving both quantitative and qualitative approaches, was employed to summarize and report the results from the selected studies following the methodological framework provided by Arksey and O\u0026rsquo;Malley [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. We first performed numerical analyses to describe the characteristics of the included studies including their geographical distribution, study designs, study population and interventions. Thematic analysis was then used for in-depth synthesis of findings of the included studies allowing for cross-study comparisons. The results were reported using tables and figures and complemented with the narrative description of the key themes emerging from the synthesis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom an initial 6135 results retrieved from the literature searches, we included 10 studies [\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] from eight LMICs. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the PRISMA flow diagram describing the study selection process.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eStudy Characteristics\u003c/h3\u003e\n\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the characteristics of the included studies by country and continent, methodology, climate hazard studied, facility type and target population.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere were two studies from India [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and one was from Pakistan [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Two studies came from Southeast Asia, Vietnam [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Nepal [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Sub-Saharan Africa was represented by South Africa [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and Nigeria [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. One study originated in the Middle East, in Iran [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and another in East Asia, in South Korea [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. North America was represented by Haiti [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe studies drew on a wide range of methods. In South Africa and Nepal, Naidoo et al. (2022) and de Almeida et al. (2021) used interviews and documentary analysis. Minh et al. (2014) blended surveys, interviews, and focus groups to map how district and commune facilities in Vietnam adapt to storms and floods. A structured quantitative design [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] tested a heat-training programme through a multicentre pre\u0026ndash;post study in Pakistani emergency departments, while Kakkad et al. (2014) analysed hospital records. Other quantitative studies, for example, Alok et al. (2025) in a Haitian clinic and Amadi et al. (2025) in Nigerian neonatal care examined clinical outcomes directly after interventions. Mishra et al. (2025) integrated facility-level indicators with staff interviews to explore resilience-building across India\u0026rsquo;s public health system. An et al. (2025) used experimental trials and Computational Fluid Dynamics (CFD) simulation to test air-purifier performance in a simulated Korean hospital ward.\u003c/p\u003e \u003cp\u003eTwo studies examined storms and flooding [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and two focused on heat-related hazards [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Hurricanes shaped one study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], while earthquakes featured across two others [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Air-quality risks were explored in studies on outdoor pollution [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and indoor ventilation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. One study addressed high-carbon-footprint neonatal care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe studies engaged a broad range of health facility types, including district and commune-level public health facilities [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], emergency departments [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]), neonatal and hospital wards [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and teaching hospitals and prenatal clinics [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTarget populations varied. Two studies centred on health managers and facility leaders [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and three focused on frontline healthcare workers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Neonates were the focus in two studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], pregnant women in one [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and broader community groups in two [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. One study involved immunocompromised hospital patients [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eApplication of the WHO Climate-Resilient Health System Framework\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the WHO conceptual framework for building climate-resilient health systems, which was used to guide the analytical lens for this review [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The framework outlines ten core components including leadership and governance; health workforce; climate and health risk and vulnerability assessment; integrated risk monitoring and early warning; health and climate research; climate-resilient and low-carbon health care facilities and technologies; management of environmental determinants of health; climate-informed health programmes; emergency preparedness and disaster risk management for health; and climate and health financing [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In the sections that follow, we first present the results of our synthesis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Supplementary Table\u0026nbsp;1) and then compare these findings against the WHO framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) in the discussion section to identify areas of alignment, implementation, and remaining system level gaps.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClimate-Related Adaptation Themes Across Studies\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the main climate related adaptation themes identified from the review. Four overarching themes emerged: (1) capacity building; (2) structural adaptation and facility preparedness; (3) water, sanitation and hygiene (WASH) and emergency response beyond health facilities; and (4) barriers and challenges (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\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\u003eClimate-Related Adaptation Themes Across Studies\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\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription of Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExamples From Literature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOutcomes Reported\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapacity Building\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthening staff skills in diagnosis, emergency response, treatment protocols and community education.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeat-emergency training; simulation drills; motivational interviewing; hygiene and water-safety education.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImproved diagnosis; stronger emergency response; better treatment decisions; increased community preparedness.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKhan 2023; Minh 2014; Araban 2017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStructural Adaptation and Facility Preparedness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical and environmental changes to improve resilience, energy reliability, cooling and ventilation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRelocating neonatal wards; solar panels; reorganised hospital spaces; backup generators; optimised air purifiers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduced heat-related morbidity; improved thermal comfort; more reliable energy; stronger continuity of care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKakkad 2014; Amadi 2025; Mishra 2025; de Almeida 2021; An 2025; Naidoo 2022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWASH and Emergency Response Beyond Facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproving water systems, sanitation, hygiene practices and community resilience; activating emergency response.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRO systems; sanitation stations; disease surveillance; mobile outreach; temporary water supply; community meetings.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImproved water safety; reduced contamination; better disease detection; maintained services during floods.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMishra 2025; Minh 2014; Naidoo 2022; Alok 2025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers and Challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-cutting constraints including weak infrastructure, governance gaps, staffing shortages and limited resources.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDamaged facilities; unclear emergency roles; weak early warning; insufficient staff; missing data; emotional strain.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduced effectiveness of interventions; delayed response; inconsistent practice; difficulty maintaining care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNaidoo 2022; Minh 2014; Khan 2023; de Almeida 2021; Kakkad 2014; Alok 2025\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\u003e \u003cb\u003e1. Capacity Building for Climate Related Health Preparedness\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur review found that capacity building interventions targeted both health workers and the communities they serve. Structured training programmes strengthened technical competencies and decision-making capacity for climate-related emergencies. In Vietnam, Minh et al. (2014) incorporated disaster simulation drills, first aid and emergency care training, and pre-season readiness activities that equipped health workers and village health teams for storm and flood events. Mishra et al. (2025) also reported training initiatives for staff and resident doctors to manage seasonal climate related surges, including those linked to storm-associated disease patterns. In Pakistan, Khan et al. (2023) demonstrated that the HEAT educational programme, which included workshops, simulation exercises, wall-mounted algorithms, and pocket-sized clinical manuals, improved diagnostic accuracy for heat-related conditions and increased the use of appropriate cooling techniques in emergency departments.\u003c/p\u003e \u003cp\u003eSeveral interventions extended beyond health facilities to build preparedness at the community level. Minh et al. (2014) delivered education on hygiene, water safety, first aid, and storm-related risks, strengthening household preparedness and supporting more effective community responses during storms and floods. Araban et al. (2017) implemented a behavioural education programme for pregnant women that improved preventive behaviours and self-efficacy in reducing exposure to air pollution through motivational interviewing, educational materials, and daily SMS alerts. Mishra et al. (2025) introduced WASH-related behavioural supports, including sanitary stations and hygiene-promotion materials, which improved community water safety but were constrained by maintenance requirements and limited resources. Minh et al. (2014) additionally reported challenges in sustaining community engagement with water safety messaging.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Health Facility Preparedness, Structural Adaptation, and Low-Carbon System Resilience\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur findings reveal that facilities are adopting combined infrastructural, technological, and energy-efficiency strategies to enhance climate resilience while reducing operational vulnerabilities. Five studies reported interventions aimed at strengthening facility preparedness and structural resilience to climate-related hazards, including heat, storms, pollution, and energy instability [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Facilities undertook spatial and infrastructural modifications to protect patients and ensure service continuity under extreme conditions. In India, Kakkad et al. (2014) demonstrated how relocating neonatal wards from the overheated fourth floor to the cooler ground floor reduced heat-related neonatal morbidity. In South Africa, Naidoo et al. (2022) highlighted rapid spatial and operational reconfigurations during flooding, enabling facilities to continue providing essential care despite environmental disruption. Alok et al. (2025) strengthened infrastructural capacity through extended operating hours, expanded staffing, and improvements to supply chains and outreach systems, supporting ongoing care in resource-limited, climate-sensitive settings. An (2025) showed how optimised air purifier placement within clinical wards reduced particulate exposure for vulnerable patients. Integrated within this broader structural adaptation agenda were sustainability and low-carbon initiatives aimed at improving energy security and reducing environmental impact. Mishra et al. (2025) reported installation of solar panels, energy-efficient lighting, and conservation practices alongside reverse-osmosis systems to ensure clean water, contributing to both resilience and reduced emissions, though implementation was limited by cost and maintenance requirements. Similarly, Amadi et al. (2025) demonstrated how a solar-powered neonatal device expanded access to essential care in remote, off-grid settings.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. WASH Improvements and Emergency Response Measures beyond Health facilities\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAlthough the primary focus of this review was on facility-level interventions, we found that several facilities implemented actions that extended beyond the facilities into the communities they serve. For example, Minh et al. (2014) delivered ongoing community education on hygiene, water safety, first aid, and storm-related risks, which helped strengthen household preparedness and supported more effective community-level response during storms and floods. Similarly, Araban et al. (2017) implemented a behavioural education programme for pregnant women including motivational interviewing, educational materials, and daily SMS alerts which improved preventive behaviours and self-efficacy in reducing exposure to air pollution. Interventions related to water and sanitation resilience were reported in two studies. Mishra et al. (2025) described the installation of reverse-osmosis systems, sanitary stations, and WASH-related behavioural supports, which improved water safety but were constrained by maintenance demands and limited resources. Minh et al. (2014) implemented community-oriented water safety activities, including hygiene education and preparedness messaging, which helped reduce contamination risks during storms and floods, however community outreach was challenged. Emergency preparedness and disaster response measures were identified in four studies. Besides strengthened WASH system, Mishra et al. (2025) highlighted essential medicine stocks, and staff training and. Minh et al. (2014) reported structured pre-season planning, disaster simulation drills, and emergency kit stocking that enhanced storm and flood readiness. Naidoo et al. (2022) documented rapid operational adjustments during flooding, including staff redeployment, extended service hours, and mobile outreach to maintain essential care. De Almeida et al. (2021) described activation of a hospital disaster plan that facilitated coordinated task-sharing, flexible staff deployment, and prioritisation of emergency services during a surge in trauma cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4. Barriers and challenges\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe review found that structural and systems level barriers such as damaged infrastructure, unreliable power, and inadequate WASH and ventilation systems disrupted service delivery in South Africa [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], Vietnam [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and Nepal [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In India, neonatal wards located on the hottest floor exacerbated heat vulnerability before relocation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], while older hospital buildings in Korea reduced the efficacy of air-purification interventions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Weak governance and planning such as the absence of early warning systems, unclear roles, fragmented coordination, and insufficient funding constrained preparedness across South Africa, Vietnam, and India [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Resource shortages, including a lack of supplies, inconsistent stock, and limited equipment, were commonly reported, with financial constraints preventing expanded trials of climate-responsive technologies in Nigeria [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe review also established that the workforce, behavioural, and contextual barriers shaped the uptake of climate adaptation measures. Several studies reported insufficient training, uneven staff capacity, and heavy workloads as impediments to implementing emergency practices, particularly in Pakistan\u0026rsquo;s emergency departments [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and in Vietnam\u0026rsquo;s primary care system [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Emotional stress and staff fatigue further constrained response efforts during the Nepal earthquake [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. At the community level, behavioural recommendations sometimes conflicted with daily responsibilities, limiting adherence among pregnant women in Iran [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In Haiti and India, incomplete clinical data and lack of disease coding hindered accurate assessment of climate-sensitive conditions [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review examined what climate-related interventions and adaptations are taking place within health facilities in low- and middle-income countries. Our findings show that some facilities are already responding to climate pressures through training initiatives, structural modifications, emergency preparedness measures, WASH improvements, and low-carbon technologies.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCapacity building\u003c/strong\u003e \u003cp\u003eAcross the studies in this review, capacity building was one of the clearest pathways to improving readiness for climate related health risks. Training and simple clinical tools helped staff respond more effectively during extreme events. In Pakistan, training improved how emergency providers recognised and managed heat emergencies [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In Vietnam, preparedness exercises and clearer guidance strengthened coordination and early response [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Staff in Nepal also reported that shared roles, flexible decision making, and prior drills helped them cope during the earthquake response [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These examples show that even minimal training efforts can shift confidence, decision making, and the organisation of care inside health facilities. Evidence from high income countries supports this pattern. For example, after the 2003 heatwave in France, national heat preparedness activities that included seasonal training and clearer clinical protocols were introduced [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. A later heatwave in 2006 caused far fewer deaths, partly because professionals were more aware and better prepared [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In England, on the other hand, the Heatwave Plan requires hospitals, general practice teams, and community services to train staff ahead of each summer season [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eStructural adaptations\u003c/span\u003e identified in this review reflect patterns already documented in high income countries (HIC) where infrastructure resilience is seen as central to clinical preparedness. Investments in building upgrades, protected power systems, improved ventilation, and strengthened water infrastructure to maintain safe conditions during heatwaves, storms, and floods [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These developments help contextualise the LMIC findings. Even modest changes such as cooler clinical spaces, reliable generators, or a more stable water supply supported continuity of care during climate pressures. Evidence from HIC also shows that resilient health facilities, diversified energy and water sources can reduce service disruptions and protect vulnerable patients [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The structural adaptations emerging in LMIC facilities, though often achieved with limited resources, are aligned with global best practice.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eThe WASH and community preparednes\u003c/span\u003es measures identified in this review echo wider evidence from high income settings, where strengthened water systems, hygiene protocols, and community outreach form core elements of climate resilience. Studies from Europe and North America show that hospitals and public health authorities increasingly pair facility level WASH improvements with broader emergency coordination, including early warning systems, community risk communication, and cross-sector planning during floods, storms, and heat events [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These models help contextualise the LMIC findings as seen in Vietnam, where pre-season planning, expanded hygiene education, and strengthened disease surveillance improved local readiness for flood related surges [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In India, investments in water treatment systems, sanitation stations, and waste segregation supported safer service delivery during seasonal climate-related pressures [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In Haiti, community outreach, vaccination drives, and hygiene promotion helped sustain routine care and reduce infections in areas experiencing environmental stress [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similar approaches in high income settings, such as integrated water safety plans, joint emergency command centres, and coordinated risk communication show that WASH resilience and community engagement are the most effective interventions in adverse events.\u003c/p\u003e \u003cp\u003eOverall, structural weaknesses, limited resources, and unclear emergency systems constrained the effectiveness of climate-related interventions across the health facilities. Workforce shortages, inadequate training, and high patient loads further reduced the ability of staff to respond consistently during climate pressures. These barriers mirror challenges seen in high income settings.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAlignment with WHO Climate-Resilient Health System Framework\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents how the included studies in this review align with the pillars of the WHO framework, highlighting the gaps in evidence across dimensions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAs illustrated in the results and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, most documented interventions cluster around three domains: climate-smart health workforce development [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], climate-related emergency preparedness and management [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and climate-resilient infrastructure and technologies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. While these interventions demonstrate efforts to strengthen resilience under worsening climate pressures, they remain highly localised, small in scale, and poorly integrated into broader system planning. Overall, the ten studies from the review shows minimal implementation of climate-resilience measures across LMIC health facilities, with adaptations tending to be reactive and facility-specific rather than embedded within coordinated, system-wide strategies.\u003c/p\u003e \u003cp\u003eEqually striking are the components of the WHO framework that were entirely absent. No studies addressed climate-transformative governance, sustainable climate and health financing, integrated risk monitoring or early warning systems, climate-informed health programmes, or climate and health research domains critical for long term system resilience. These omissions, coupled with structural vulnerabilities, weak governance, fragmented coordination, resource shortages, limited staff capacity, and behavioural constraints, reveal some of the systemic barriers limiting adaptation. The findings suggest that LMIC health facilities remain far from operationalising the WHO framework and highlight the need for strengthened governance, dedicated financing, integrated surveillance and early-warning capacities, and the routine incorporation of climate considerations into health system planning and service delivery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis scoping review provides one of the first systematic examinations of climate related interventions and adaptations within health facilities in low and middle-income countries. Incorporating qualitative, quantitative, and mixed-methods studies from diverse settings, offered a comprehensive view of how facilities are responding to climate pressures in routine practice. The thematic synthesis covering capacity building, structural adaptation, WASH improvements, and system barriers provides a clear framework for interpreting heterogeneous evidence. The review also identifies important gaps in knowledge, helping to shape priorities for future research on climate resilience in health facilities.\u003c/p\u003e \u003cp\u003eThis review is shaped by several limitations. The evidence on climate related adaptations in LMIC health facilities is still sparse and uneven, with many studies describing small, context specific interventions and offering limited outcomes or follow up. Inconsistent reporting, particularly on indoor conditions, resource constraints and implementation processes, reduced comparability across settings. Relevant studies may also have been missed because climate and health systems research is poorly indexed, especially in grey literature. Finally, as a scoping review, we did not appraise study quality, which limits the strength of any causal interpretations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eClimate related adaptations and interventions in LMIC health facilities remain narrow, uneven, and reactive. While pockets of innovation exist, they touch only a fraction of the components outlined in the WHO 2023 framework. Our review shows that even small-scale interventions can bolster preparedness, yet system-wide resilience remains out of reach without stronger governance, sustained financing, robust surveillance, and investment in infrastructure and workforce capacity. As climate pressures intensify, expanding the evidence base and embedding climate readiness into the core of health system planning will be important if facilities are to move beyond improvised responses toward genuine climate resilience.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors have no competing interests.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors received no funding for this review. JOO and CA are funded by Wellcome Trust as part of a doctoral training grant [218462/Z/19/Z] to pursue PhD in Public Health Economics and Decision Science at the University of Sheffield.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAL, BN, JOO and SO conceived the study, led the design, and contributed to data extraction, data cleaning, writing and manuscript review. JOO conducted the literature search. JOO, CA, and ST contributed to data screening, data extraction, drafting of the manuscript and review. GM, VP, MM and JP contributed to data screening, extraction and review of the manuscript. JOO and CA performed the data wrangling, manipulation and visualisation to generate the study figures. All authors critically read, reviewed and approved the final manuscript for publication.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge Evelyne Shu and Julian Natukunda for their assistance with data extraction, and the University of Botswana librarian, Mr. Khutsafalo Kadimo, for supporting the literature search.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe review draws exclusively on publicly accessible literature; therefore, all data are available within the sources cited, and no new datasets were produced by the authors. The R code for reproducing Fig.\u0026nbsp;1 is stored on this Github repository (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://github.com/mcogutajamo/Climate_Adap_Review\u003c/span\u003e\u003cspan address=\"https://github.com/mcogutajamo/Climate_Adap_Review\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSt Louis ME, Hess JJ. Climate change: impacts on and implications for global health. Am J Prev Med. 2008;35:527\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeilnhammer V, Schmid J, Mittermeier I, Schreiber F, Jiang L, Pastuhovic V, et al. Extreme weather events in europe and their health consequences - A systematic review. Int J Hyg Environ Health. 2021;233:113688.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatwary MM, Bardhan M, Haque MA, Moniruzzaman S, Gustavsson J, Khan MMH, et al. Impact of extreme weather events on mental health in South and Southeast Asia: A two decades of systematic review of observational studies. Environ Res. 2024;250:118436.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePardon MK, Dimmock J, Chande R, Kondracki A, Reddick B, Davis A, et al. Mental health impacts of climate change and extreme weather events on mothers. Eur J Psychotraumatol. 2024;15:2296818.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEbi KL, Vanos J, Baldwin JW, Bell JE, Hondula DM, Errett NA, et al. Extreme weather and climate change: Population health and health system implications. Annu Rev Public Health. 2021;42:293\u0026ndash;315.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyan SJ, Ebi K, Welburn S, Singer B, editors. Addressing vulnerability, building resilience: community-based adaptation to vectorborne diseases in the context of global change Kevin Louis Bardosh1,2. Sadie J.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEbi KL, Berry P, Campbell-Lendrum D, Ciss\u0026eacute; G, Hess J, Ogden N, et al. Health System Adaptation to Climate Variability and Change. Washington, DC; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnsah EW, Amoadu M, Obeng P, Sarfo JO. Health systems response to climate change adaptation: a scoping review of global evidence. BMC Public Health. 2024;24:2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulkarni MA, Duguay C, Ost K. Charting the evidence for climate change impacts on the global spread of malaria and dengue and adaptive responses: a scoping review of reviews. Global Health. 2022;18:1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer R, Wright C, Rother H-A. Assessment of SADC countries\u0026rsquo; national adaptation planning health impacts inclusion: A thorough review. Ann Glob Health. 2024;90:57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaser K, Haq Z, Naughton BD. The impact of climate change on health services in low- and middle-income countries: A systematised review and thematic analysis. Int J Environ Res Public Health. 2024;21:434.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNayna Schwerdtle P, Ngo TA, Hasch F, Phan TV, Quitmann C, Montenegro-Qui\u0026ntilde;onez CA. Climate change resilient health facilities: a scoping review of case studies in low and middle-income countries. Environ Res Lett. 2024;19:074041.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTricco AC, Lillie E, Zarin W, O\u0026rsquo;Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for Scoping Reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169:467\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArksey H, O\u0026rsquo;Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmadi H, Muoneke L-SC, Meremikwu MM, Udo JJ, Jimoh A, Ochigbo SO, et al. New solar-powered device for the treatment of neonatal hyperbilirubinaemia in hardest-to-reach places tested in Nigeria. BMJ Innov. 2025;11:56\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaidoo K, Manyangadze T, Lokotola CL. Primary care disaster management for extreme weather events, South Africa. Afr J Prim Health Care Fam Med. 2022;14:e1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlok A, Bakhit M, Helne D, Milord P, Socrate M, Clermont C, et al. Updating a rural clinic in tibur\u0026oacute;n, Haiti. HCA Healthc J Med. 2025;6:51\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAraban M, Tavafian SS, Zarandi SM, Hidarnia AR, Burri A, Montazeri A. A behavioral strategy to minimize air pollution exposure in pregnant women: a randomized controlled trial. Environ Health Prev Med. 2017;22:26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoitinho de Almeida M, van Loenhout JAF, Singh Thapa S, Kumar KC, Prakash Mahara D, Guha-Sapir D, et al. Hospital resilience after the 2015 earthquake in Nepal: Results from semi-structured interviews with hospital staff. Front Public Health. 2021;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2021.602509\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2021.602509\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan NU, Khan UR, Ahmed N, Ali A, Raheem A, Soomar SM, et al. Improvement in the diagnosis and practices of emergency healthcare providers for heat emergencies after HEAT (heat emergency awareness \u0026amp; treatment) an educational intervention: a multicenter quasi-experimental study. BMC Emerg Med. 2023;23:12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAn IH, Kwak DB, Lee J, Park SH, Yook SJ. Optimal operating positions of two air purifiers for improving indoor air quality in hospital wards. J Hosp Infect. 2025;159:42\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Minh H, Anh TT, Rockl\u0026ouml;v J, Giang KB, Trang LQ, Sahlen K-G, et al. Primary healthcare system capacities for responding to storm and flood-related health problems: a case study from a rural district in central Vietnam. Glob Health Action. 2014;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3402/gha.v7.23007\u003c/span\u003e\u003cspan address=\"10.3402/gha.v7.23007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKakkad K, Barzaga ML, Wallenstein S, Azhar GS, Sheffield PE. Neonates in Ahmedabad, India, during the 2010 heat wave: a climate change adaptation study. J Environ Public Health. 2014;2014:946875.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra S, Verma P, Patidar N, Katira JM, Gaonkar N, Solanki J, et al. Building climate resilient healthcare systems through interventions in Gujarat India. Discov Public Health. 2025;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12982-025-00659-7\u003c/span\u003e\u003cspan address=\"10.1186/s12982-025-00659-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Operational framework for building climate resilient and low carbon health systems. Gen\u0026egrave;ve, Switzerland: World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePascal M, Laaidi K, Ledrans M, Baffert E, Caserio-Sch\u0026ouml;nemann C, Le Tertre A, et al. France\u0026rsquo;s heat health watch warning system. Int J Biometeorol. 2006;50:144\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026eacute;mon D, Jougla E. The 2003 heat wave in France. Revue d\u0026rsquo;\u0026Eacute;pid\u0026eacute;miologie et de Sant\u0026eacute; Publique. Journal of Epidemiology \u0026amp; Community Health. 2003;62:227\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFouillet A, Rey G, Wagner V, Laaidi K, Empereur-Bissonnet P, Le Tertre A, et al. Has the impact of heat waves on mortality changed in France since the European heat wave of summer 2003? A study of the 2006 heat wave. Int J Epidemiol. 2008;37:309\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS. heatwave PLAN FOR ENGLAND: PROTECTING HEALTH AND REDUCING HARM FROM EXTREME HEAT AND HEATWAVES. 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElstow K. Tracking climate adaptation in hospitals: An inventory of structural measures to adapt the external, internal and systems assets of hospitals to anticipated climate changes. Sustainable Cities and Society; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaterson J, Berry P, Ebi K, Varangu L. Health care facilities resilient to climate change impacts. Int J Environ Res Public Health. 2014;11:13097\u0026ndash;116.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeltenrich N. Safe from the storm: Creating climate-resilient health care facilities. Environ Health Perspect. 2018;126:102001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHcwh E. Practical guide for building climate-resilient health systems. 2024.\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":"[email protected]","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 facilities, adaptation, intervention, low- and middle-income countries","lastPublishedDoi":"10.21203/rs.3.rs-8539861/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8539861/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eClimate change is intensifying pressures on health systems, with facilities in low- and middle-income countries (LMICs) facing the greatest risks due to existing structural vulnerabilities. However, little is known about how these facilities are adapting or strengthening their resilience to climate-related shocks. This scoping review addresses this gap by synthesising documented climate-related adaptations and interventions in LMIC health facilities and assessing their alignment with the WHO 2023 Operational Framework for Climate-Resilient and Low-Carbon Health Systems.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSearch terms were applied to MEDLINE, PubMed, Embase, Web of Science, Scopus, CINAHL and APA PsycINFO electronic databases, for articles published from inception to July 2025. Studies from LMICs, related to climate change and focused on health facility adaptations were included. Articles were extracted in Covidence software, and a narrative synthesis approach applied to identify key themes and patterns in the articles.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, ten studies met the inclusion criteria. India contributed three studies, while Pakistan, Vietnam, Nepal, South Africa, Nigeria, Iran, and South Korea each contributed one. Our results reveal a narrow concentration of interventions across three domains (1) climate-smart health workforce development (2) climate-related emergency preparedness and management and (3) climate resilient infrastructure and technologies. Reported actions included simulation-based training, community-oriented education, ward relocation, ventilation and air-purification improvements, solar energy installations, water purification systems, and rapid spatial reconfigurations during floods. Although these interventions demonstrate efforts by facilities to maintain continuity of care under climate pressure, they remain small in scale, highly localised, and largely reactive. Several critical components of the WHO framework such as climate-transformative governance, sustainable financing, integrated risk monitoring and early warning systems, climate-informed health programmes, and climate and health research were entirely absent in the review. Barriers to adaptation included infrastructural vulnerability, weak governance, fragmented coordination, limited resources, workforce constraints, and behavioural challenges.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eClimate related adaptations in LMIC health facilities remain limited, but available evidence shows that even small changes can strengthen resilience. Practical steps such as staff training, better infrastructure, stronger WASH systems, and clearer emergency procedures improve readiness and help keep care running during climate shocks. Yet major gaps remain, especially in long term evaluation and in the structural and governance weaknesses that limit sustained progress. Building a stronger evidence base and investing in facility resilience will be critical as climate risks continue to rise.\u003c/p\u003e","manuscriptTitle":"Not Enough to Meet a Growing Threat: A Scoping Review of Climate Adaptation and Intervention Strategies in Health Facilities across Low- and Middle- Income Countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 15:51:40","doi":"10.21203/rs.3.rs-8539861/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"e512c492-7925-4882-8873-472aea2b3353","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-12T05:53:09+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-08 15:51:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8539861","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8539861","identity":"rs-8539861","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}