*1.1. Climate Change Adaptation of Health Systems*

We adopt a case-study framework of adaptation of health systems (Figure 1). For analytic purposes, the framework distinguishes between the processes of elaborating policy programmes, monitoring, and information-gathering, and enforcing protective measures. The framework recognises significant overlaps and feedback loops between these responsibilities of the Estonian health system. Effective and timely responses depend on effective **policies, strategies, and action plans** crafted by political leaders to manage climate-sensitive health outcomes. The WHO Operational Framework specifies that in order to continuously deliver health services throughout climate-related events, governments should modify emergency management plans and incorporate up-to-date risk assessments. In line with the European Union's climate change adaptation strategy [15], most European countries have developed national strategies, but few countries have implemented regulations and operational plans for authorities and healthcare systems to manage health-related issues.

**Monitoring and gathering information** of health and health system conditions provides information for timely responses and behaviour change, but also for setting new goals and amending legislation. The WHO Operational Framework [13] identifies three key areas that health information systems must develop: vulnerability, capacity, and adaptation assessments; risk monitoring; and climate and health research. Risk monitoring systems provide timely, detailed information on current and future environmental conditions that may affect health and the ability of health systems to provide services. In the context of climate change, hurdles for new interventions may arise in the form of evidence provision; climate will continue to change over coming decades, with uncertainties associated with the rate and magnitude [16,17]. The tendency of turning a "blind eye" towards policy problems by limiting investments in surveillance and monitoring may work to maintain the status quo in state investments [18].

As for timely **responses and protective measures**, monitoring systems coupled with communication networks (early warning systems) can be designed to alert members of the public when environmental hazards may affect their health. However, existing health safety programs excessively focus on providing information [19] without considering the need to change motivation and supportive infrastructure, living arrangements, and skills. For example, climate change can affect the ability of healthcare systems to provide services during extreme weather events because of infrastructure damage and medical supply disruptions [13].

**Figure 1.** Determinants of climate adaptation of health systems.
