**5. Conclusions**

The study shows the significance of the EU pressures for aligning the health systems of a small country, like Estonia, with the climate adaptation goals of building resilience to future increases in, e.g., projected storminess and length of heatwaves. However, the effect of these external pressures remains short-lived, when the political salience of climate change and the related political will is low to mainstream climate change into policies, and to invest scarce resources in adaptation policy programmes, monitoring, and protective responses. Although efforts are being made in emergency preparedness and rescue, which, as a co-benefit, increase the ability to cope with the health risks of climate-related extreme events, the state has limited avenues for pressuring the private domains of primary care and hospitals. There are significant opportunities to gain synergistic benefits from conducting risk and vulnerability analyses, and from building community resilience through mainstreaming climate change over related policy fields, including rescue services, health, environment, social care, and even education. In a situation where there is lack of issue ownership, policy integration and mainstreaming could be facilitated by appointing a responsible institution. Institutional responses resonate with people's perception and the demand for adaptation measures. As characteristic of a small health system, the shortage of regionally specific scientific assessments and lack of pressure from other organised interest groups, attenuate the social and political urgency for adaptation. Nevertheless, growing experience with extreme weather events, particularly among increasing urban and minority populations who are detached from traditional coping strategies, may increase demand for the provision of state support for health adaptation.

**Author Contributions:** K.O. conceived the research questions and design; conducted the analysis and did most of the writing of the manuscript; M.T. conducted expert interviews and participated in their analysis; K.L.E. provided advice on the data analysis and helped in writing the manuscript; H.O. conducted the population-based survey and contributed to writing the manuscript.

**Funding:** K.O.'s work on the preparation of this article was supported by the HEALTHDOX project (MSHUH14155) financed by NORFACE Programme. H.O.'s work on the preparation of this article was supported by the Estonian Ministry of Education and Research grant IUT34-17.

**Conflicts of Interest:** The authors declare no conflict of interest.
