**1. Introduction**

It is expected that the health risks of climate change will increase globally, with increases in morbidity and mortality from selected climate-sensitive health outcomes, putting additional pressures on health systems [1,2]. The effectiveness of adaptation is influenced by a country's physical location and exposure to climate shocks, levels of socioeconomic development, and healthcare capacity to prepare for and manage climate-related shocks [3]. Tailoring effective adaptation measures requires a clear understanding of which factors led to today's preparedness to manage climate change. Researchers have been urged to pay more attention to the role of the nation state in climate governance, as these actors have the legitimacy and resources to develop long-term visions, stimulate and oversee local approaches, and carry forward adaptation programs, e.g., [4]. In their analysis of health adaptation initiatives in ten Organization for Economic Co-operation and Development (OECD) countries, Austin et al. concluded that national governments play a key role in health adaptation to climate change, but there are competing views on what responsibilities and obligations this will—or

should—include [5]. One view suggests increasing investments in existing public health infrastructure to manage the projected health risks [6]. The second argues climate change will likely affect health by, for instance, destabilising supporting systems or threatening infrastructure, thus necessitating new and innovative responses. Suggested factors for successful adaptation include adopting legislation, ensuring interdepartmental coordination, and increasing self-governance [7–9]. We take an in-depth look at health and rescue systems in Estonia, because they will play a key role in climate adaptation policies in connection with the EU climate change strategy [10].

Informed by the research on risk governance [11,12], we analyse the health and rescue system as a control system for achieving policy goals; assess factors shaping those goals; and assess the factors shaping the process of information-gathering and implementation of protective measures, such as early warning systems or emergency preparations. We examine the extent to which outside (e.g., issue salience) and inside (e.g., institutional capacities and rules) drivers of the health systems shape the success of climate adaptation. We apply the World Health Organization's Operational Framework for Building Climate Resilient Health Systems [13] to understand how the quality of leadership and governance, health workforce, health information systems, medical technologies, service delivery, and climate and health financing shape the quality, efficiency, equity, accountability, and resilience of the health systems [14].
