*1.2. Factors Influencing Adaptation of Policy Programmes, Monitoring Systems, and Response Measures*

Effectively adapting to the health risks of climate change includes internal factors related to administering health systems, such as management structure and capability, and external factors, including the pressure of interest groups and the public. The **internal functioning** of health systems is often characterised by administrative cultures of reactivity and lack of long-term future orientation. The administrative focus is tightly related to the risk calculus that politicians make; this includes issues such as the visibility of the problem (which may be obvious to experts but far less so to the general public and politicians) and the avoidability of blame (for events that lead to damage) [20,21]. By contrast, the notion of institutional adaptive capacity [22] highlights the proactive provision of means and information to enable social actors to anticipate possible futures and take preventive measures.

Administrative capacity is the health system's economic aptitude, technical preparedness, and competence and sufficiency of human resources; these factors may influence the development and application of adaptation policy [23]. At lower level administrative units, larger municipalities are likely to have more human and financial resources to direct to adaptation [24,25]. Maintaining a healthy and effective practitioner workforce, products, and technologies are critical challenges for health systems [13]. Beyond human and financial resources, institutions should have the authority to generate political and legal incentives for actors to change [26].

The administrative architecture is crucial in the design of adaptation policy, as multilevel institutions and networks are needed for the process to be successful [27]. Developing effective adaptation plans requires coordination and collaboration between health ministries and other government agencies and non-governmental partners, to ensure that the actions undertaken foster positive health outcomes [13]. Policy coherence literatures (see Tosun and Lang, 2017 [28]) highlight the demanding task of integrating institutions, particularly in cases with an increasing number of affected interests, such as health [29] or security [30].

The most obvious **contextual driver** of political and administrative action is the effect of extreme events spurring increased awareness and policy innovation [18]. In general, climate change is difficult to understand and psychologically distant for lay people and political and administrative actors [31]. However, according to the policy-window hypothesis, following a disaster, the political climate may be conducive to legal, economic, and social change that can begin to reduce structural vulnerabilities [32].

Based on strong interests, non-governmental organisations, entrepreneurs, or the scientific community can influence health risk governance [12]. Robust climate and health research agendas should expand and improve the quality of knowledge [33]. However, the scarcity of scientific evidence of the emergence of climate change-related health impacts may challenge the ability to develop effective adaptation options [34].

In countries of the former Soviet Union, the role of non-governmental organisations in developing and applying regulatory regimes has been modest [18]. This may change as national groups advocating a certain policy or action gain prominence when an issue is placed on the political agenda and reaches a certain level of salience [35].

International organisations pose crucial pressures; the adoption of climate policies in the OECD countries was influenced by learning from international organisations [36]. The issue of climate change entered the political agendas of Central and Eastern European countries through the EU [37,38]. Exemplary neighbouring states are urging other EU countries to tighten their mitigation policies [36,39].

In the context of climate change, this study takes a comprehensive look at external pressures and factors characterising the internal working of the Estonian health system. We first present empirical data and methods that are used to validate our expectations. We then discuss background information about Estonia's health systems' adaptation to climate change. In subsequent sections, we discuss how the dominant ideas, administrative structures and capacities, and windows of opportunity have shaped the current situation with respect to adaptation politics.
