3.2.1. The Inner Functioning of the State Apparatus Influences the Adaptation Activities

The absence of an integrated approach to climate adaptation can be explained by the nature of the **administrative culture** of the institutions involved in the Estonian health system. On the one hand, adaptation policies are influenced by an understanding of the necessity of state intervention (or the lack thereof) and, on the other hand, the manner of making decisions and their transparency. A prevalent viewpoint is that individuals can adapt to climate change because it occurs over long time periods, so preparedness only needs to be ensured for extreme changes. As stated by a climate expert (29 April 2015): "*We need the support of the state first and foremost when health effects have occurred as a result of short and abrupt changes. For certain, human body has the ability to adapt to long-term changes*." Likewise, the majority of the interviewees found that state regulations are sufficient, and that increasing the readiness of people to cope with changing weather patterns is all that is needed. As one official from the Ministry of the Interior said (29 April 2015): "*The readiness of people to cope has decreased. This should be taught from early on*."

In coping with extreme weather events, transparency in decision-making was called into question. Interviews pointed out that although shaping policies is open to different parties, decisions in the area of health and rescue are made by a small closed group. The officials pointed out that sometimes government decisions come without explanation as to what was the motive or evidence behind a decision. As a specialist in environmental health from the Ministry of Social Affairs (4 May 2015) said: "*Today such decisions are made in politics the background of which is not known even to us—no matter have the*

*scientists or experts been involved or not*." There was no evidence supporting the hypothesis that there is a change in the climate-related norms of the political actors in Estonia or for growing support for climate adaptation policy.

The administrative architecture is important for monitoring climate change-related health effects and assessing the readiness to cope with emergencies; these are lagging due to the dispersal of responsibilities across institutions. A specialist in public health discussed the challenge of not having an owner of the issue of the health risks of climate change: "*Climate health effects, as environmental health in general, is a highly cross-sectoral phenomenon and nobody really wants to claim the problems and take responsibility for the area*." A specialist in environmental health in the Ministry of Social Affairs (4 May 2015) brought out problems in distributing resources in connection with the application of measures and executing control: "*The Ministry of the Environment has the money and the Ministry of Social Affairs has the problems, however, the ministry will not allocate money to solve the problems. The fragmentation of the area between the ministries would not even be a problem if there was clarity as to which ministry should be paying for solving the problem*."

Distributing responsibilities between ministries with insufficient cooperation between them results in problems when dealing with emergency situations associated with climate change, as was pointed out by a representative of the Rescue Board (7 June 2015): "*Each ministry has their own plans for coping in different situations, but there is no general plan*." A representative of the Rescue Board (18 June 2015) said: "*Currently, the Ministry of the Interior is the coordinator of crises situations and other ministries do not want to come along in this matter. The Ministry of the Interior does not have the means to force other ministries either. This is why such freewheeling exists. Since the state has not given any direct guidelines the departments just see how they can manage*." A family physician (7 May 2015) commented on the ability of healthcare to react in case of emergency situations: "*Everybody is doing what comes to mind. There is no uniformly controlling agency to whom to turn to. The tasks and who precisely is responsible for what has not been clearly determined. This is a very topical problem*." A representative of Rescue Board said: "*It would be complicated to get the hospitals and doctors behind one table, to map their resources and situation, because they are private bodies. One can only assume that when something happens that would exceed the capacity of a local hospital, other hospitals would accept the patients; however, there is actually no certainty in this matter*." The issue of silos of primary healthcare, emergency situations, and social care was also stressed by a city medical officer (12 June 2015): "*Now when the family physicians are no longer part of local governments and the communication takes place through Ministry of Social Affairs, the health care part is distancing itself from the local governments' health adaptation issues*."

One of the factors influencing the **administrative capability** to cope with climate change on the state level is the scarcity of the necessary expertise. A separate programme for environmental health to address adaptation issues was not considered necessary. There is almost no continuing medical training in environmental health for physicians. Climate change-related health risks are an unknown territory for social care professionals. As an expert in social work (4 March 2015) explained: "*A social worker or caretaker does not have the knowledge about what kind of weather conditions present danger and how to prepare a ward. The current activities are all a creative effort on the spot*."

Lack of financing has inhibited monitoring, integrating databases to assess health effects and rescue necessities, and diversifying information systems. Creating a common pool of resources and synergies by coordination of information systems is resisted for a paradoxical reason mentioned by an official from the Ministry of the Interior (29 April 2015): "*We are, nevertheless, a poor country. There is a fight in departments for money and for each individual*." Poor preparedness of medical infrastructure and staff are explained by a lack of financing and prioritisation. The interviewed medical workers stressed the inadequacy of human resources to cope with climate-related disease outbreaks. As a family physician (7 May 2015) explained: "*As for today, we don't have extra resources in case of an outbreak.*" At the same time, some officials claimed there are insufficient human resources to ensure the capability to deal with climate change-related health risks. An official from the Ministry of the Interior (29 April 2015) said: "*Climate change is currently highly unlikely and the effect climate change has does not exceed the usual*

*capability of the hospitals; we do not treat this as a likely emergency right now*." This also explains the insufficient investment into cooling systems for hospitals and care homes.
