**4. Discussion**

Our research clarified the factors determining the preparedness of the health system in Estonia to manage the health risks of climate change. The study was conducted in 2015, when health adaptation had not been legally defined. The material analysed was used as background material for compiling the strategy "Climate Change Adaption Development Plan until 2030" that was ratified by the Estonian parliament in 2017 [70]. A "Climate Change Adaption Development Plan's Action Plan for 2017–2020" was subsequently agreed upon. However, the resources dedicated for the action plan were a magnitude smaller than what was proposed [71]. Therefore, many of the problems raised in the study remain to be addressed. Our analyses take an in-depth look at one country, Estonia. The lessons learned could be of relevance for other countries with similar Eastern European backgrounds. In some Eastern

European countries (e.g., Poland), climate change adaptation and mitigation are taken seriously at the city level [25]. However, Eastern European countries, including Estonia, fall far behind Finland, Sweden, and the United Kingdom in adaptation planning and implementation.

The policy innovation literature, e.g., [4,72] offers some clues as to the circumstances under which adaptation policies emerge, e.g., bringing out the role of leadership and the state's participation in international organisations. However, the literature stops short in giving an integrated look at the drivers behind implementation, monitoring, and protective responses. We took a broader look at the health systems functioning and the variety of drivers shaping its effectiveness and equality in provision. An in-depth case study allowed exploration of the mechanisms behind the adoption and implementation of adaptation policies, including the broader perspective of health systems, particularly prevention, healthcare provision, and rescue services.

The WHO Operational Framework foresees that for effective policymaking activities, policymakers and other stakeholders require accurate, timely information on health and health system conditions. However, up until the initiation of baseline studies for a climate adaptation strategy pursuant to the EU Directive [15], there had been no studies on climate change and related health systems functioning. Our analyses confirm the findings by Massey et al. [23] that external drivers, primarily, the centrality of EU is required for the diffusion of adaptation policies across Europe. EU institutions are important driving forces for gathering information, especially in improving monitoring and early warning systems.

It has been argued that the "EU values" on climate change are not internalised by the political actors in Central and Eastern Europe [25]. The analyses in this paper highlight several key impediments for why health systems have not fully adopted these ideas. One is the **style of regulation**. The market liberal state approach characteristic of environmental health governance in Estonia can dissociate responsibilities with the "lean state" rhetoric [18]. The overruling perspective among policymakers is that if climate change occurs at all, then people should be able to cope with the long-term effects by themselves. Such a perspective can be explained by limited economic capacity and the lack of evidence. This dissociation of responsibilities is understandable as the evidence pointing to the need for intervention is scarce, and longer-term planning based on projections of the health risks of climate change is limited. The tendency of turning a "blind eye" towards policy problems by limiting investments in monitoring and inspection also occur in other environmental health issues [18]. We may assume that health systems in other small countries with dispersed human, financial, and political resources may lack the resources necessary for adaptive capacity [22] to deal with what is still often considered as an avant-garde issue of climate change risks.

Even if the capability to cope during acute situations exists, there is no certainty as to the extent to which family physicians and hospitals operating under the private law would be ready for extreme events. Maintaining an informed and effective practitioner workforce is a critical challenge for health systems grappling with extreme events [13], however, no contingency plan has been elaborated for hospitals. Limited preparation and the state approach of minimal interference has important implications for the safety of the most vulnerable population groups, including elderly and minority groups.

Our results highlight the significance of the **regulatory architecture and the related allocation of responsibilities**. Climate change-related health risks are highly cross-sectoral, which means that other state departments are expected to assume primary responsibility. In extreme weather conditions, healthcare systems and rescue services will indeed cope within the limits of their competences, but in case of more complex issues, prevention and timely responses are inhibited by the lack of cooperation between rescue and social services, and healthcare providers. Also, for information-gathering, monitoring of some parameters or vulnerable groups is organised separately, fragmented between institutions. Fragmentation inhibits the integrated assessment of climate change-related health and related risks and vulnerabilities. Furthermore, lack of coordination and integration impedes accessing a range of possible solutions. The process of mainstreaming a policy issue (also called

policy integration [73]) through the integration of adaptation policy and measures into ongoing national sectorial planning is expected to increase policy coherence, minimise contradictory policies, and capture the opportunities for synergistic efforts in terms of increased adaptive capacity [74]. However, developing cross-sectorial policy goals becomes more demanding with an increase in the number of affected institutions and interests [75,76]. A solution addressing the institutional and organisational dimension of the problem would be to appoint a responsible institution that could facilitate policy integration in-between existing policy pillars. Attempts at mainstreaming are also more likely when the issue receives political attention [24]. The EU Climate Adaptation Strategy has been an important force to increase the political salience of the topic. However, this has yet to translate into actual better coordination between the institutions.

Our analysis shows the **societal and institutional silencing** of the health risks of climate change. Institutional responses constitute important influences on people's perceptions [77], and the implementation of adaptation measures require some degree of demand from citizens [78,79]. The low level of worries and attention to climate change adaptation measures can be explained through the limited "pool of worries" hypothesis, and the tendencies of attenuation of risk in countries preoccupied with socioeconomic instability. With the increase in income levels, the East of Europe countries are expected to increase their concern with respect to climate change [80,81]. Although there is an increase in levels of concern in Eastern member states, including Estonia, instead of these countries "catching up" with the levels of concern of southern and northern EU countries, the Eurobarometer studies show an increase in the relative difference between the average levels of concern in these groups of countries [68].

Low level of engagement with adaptation has been attributed to a lack of knowledge of climate change and related adaptation issues [82,83]. Although experience with weather-related phenomena may give rise to a perceived need for adaptation action [84–86], Estonia has yet to experience any major weather extremes (except for a major heatwave in 2010 [87]. This may have impeded awareness of the risks amongst the public. The low demand for health adaptation may also be explained by the general population being used to relatively extreme weather over four seasons (a few hot weeks are warmly welcomed). Further, the geographical size of the country may play a role, as the small size of the country decreases the chances of anything happening, leaving an impression that climate-related events that happen in other, even close-by countries, do not affect our safety and wellbeing. It has been argued that extraordinary storms and heatwaves can result in a focus on the current emergency, leaving the long-standing risks unattended [20]. However, the Estonian case indicates that increased experience with attention-grabbing extreme events in the northeastern parts of Europe could bring to the fore the need to consider long-term climate trends, and risks for health and health systems.

The occurrence of extreme weather events, coupled with research projecting that these are likely to increase in frequency and severity, resulting in increasing costs in the future, motivates richer states [23]. In the case of Estonia, an upper-middle income country, the lack of public and political salience means research of climate change-related health effects is less of a priority. The associated lack of evidence, in turn, may inhibit raising public awareness and efforts to establish health adaptation goals and implement policies and programs, including increasing individual and community-based capacities to respond to emergencies. Recent projections indicate substantial increases in summer temperatures by the end of the century over central and Eastern Europe [88], along with projected increases in pollution levels (near-surface ozone and aerosol particles) [89]. Health risks will increase under these projections, unless proactive adaptation is undertaken.

Ethnic minorities (mainly Russian-speaking) and city-dwellers are more worried about climate change, and express higher demand for protective measures. Their concerns can be explained by their social status, and the perceived level of control a person has over one's physical or psychological wellbeing. As shown also in the literature on risk perception among minority groups [90], the demand for measures is high among individuals with weakened positions, and who, in general, may have restricted ability to influence decision-making. This has further implications for managing the vulnerability of minority groups. Their perceived inhibited access to informal and institutional support may be an indication of actual vulnerability, but also a lack of awareness of support networks. As a novel finding, respondents in urban areas expressed higher demand for measures for coping with the health risks of climate change. A possible explanation for the urban dwellers' higher demand for protective measures could be attributed to their dependence on urban expert systems and infrastructures that may make city dwellers feel more vulnerable, with a general sense of higher exposure to extreme weather events. In rural areas, individuals have lower expectations from the state, being situated further away from expert systems; they have maintained skills to cope with current extreme weather events, but may not be prepared for future, more extreme events.
