31st August 2018, Volume 131 Number 1481

Hayley Bennett, Paula King

The reality and potential severity of human-caused climate change is now well known,1–2 along with an understanding of the inter-relationships between climate change and health.3–7 As global average temperature rises, negative health impacts from phenomena such as excess heat, extreme weather events, food insecurity and changes in infectious disease patterns will increase.3–7 The magnitude of these health impacts will vary by age, ethnicity, health status, geographic location and socioeconomic circumstances—with the greatest impacts falling on communities, including Indigenous peoples, who have contributed least to greenhouse gas (GHG) emissions.4,7–9

For Māori in Aotearoa/New Zealand, climate change will intensify the adverse and inequitable burden of ill-health that is the result of historical and ongoing processes of colonisation.10 Unless there are urgent and substantial pro-equity policy changes both within and beyond the health and disability sector, climate change will exacerbate health inequities.8,9

We argue that with the current ministerial directives to prioritise action on both health inequities and district health board (DHB) greenhouse gas emissions,11–13 DHBs have the opportunity to plan pro-equity climate and environmental sustainability actions that address both priorities. Pro-equity climate change and environmental sustainability action by DHBs will also fulfil legal mandates under the New Zealand Public Health and Disability Act 2000 for DHBs to 1) reduce (with a view to eliminating) health inequities by improving health outcomes for Māori and other population groups; and 2) exhibit a sense of environmental responsibility by having regard to the environmental implications of their operations.14

Health and disability sector greenhouse gas emissions—impacts and opportunities

Greenhouse gas emissions from health systems in developed countries are substantial, making up around 3–10% of total national emissions.15–17 Hospitals in particular are very energy intensive, produce large amounts of waste, have large transport and procurement carbon footprints, and emit some gases with very high global warming potential (eg, anaesthetic gases).15–18

It is acknowledged that our health and disability sector is contributing to health-harming climate change, and that causing harm in this way is contrary to the fundamental purpose of promoting, protecting and restoring health and wellbeing.19 Those health organisations that face up to their responsibilities to reduce GHG emissions find that action to reduce emissions and improve environmental sustainability can bring co-benefits such as saving money, improving the quality and resilience of health services, and improving staff and community wellbeing more widely.20–25 Forward looking health systems around the world are acting now to reduce GHG emissions, improve sustainability and increase climate change preparedness.26–28 However, to date health organisations have not considered how they can ensure that their climate change and environmental sustainability actions align with the achievement of health equity.

Why climate change and environmental sustainability action by DHBs must be pro-equity

When poorly designed and implemented, health services and new health initiatives/programmes can maintain or make worse existing health inequities that stem from the inequitable distribution of resources that determine health.29 Aotearoa/New Zealand has several examples of health inequities being made worse by health organisations, as well as the introduction of new programmes locally or nationally. For example, inequities in the quality of primary and secondary health care for Māori,30–36 and ethnic inequities in participation rates for the Bowel Cancer Screening Pilot.37 If DHBs choose not to apply pro-equity thinking, planning and accountability mechanisms in the rollout of climate change and environmental sustainability actions, then there is a real risk of maintaining or worsening health inequities. For example, if cost savings resulting from interventions (eg, energy savings) were reinvested into existing primary and secondary care services as they currently operate, the inequities in health care for Māori would be perpetuated.30–36 However, the opposite could be possible if health equity underpins all climate change and environmental sustainability actions in the health and disability sector.

There is currently very little in the published literature about the deliberate pairing of climate change and environmental sustainability action in health systems with health equity goals; although large health organisations like the National Health System (NHS) in England and Kaiser Permanente in the US have linked sustainability in health organisations to wider ‘social value’.38–40

The NHS in England has a goal in its ‘Sustainable Development Strategy for the Health and Care System’ to take every opportunity to contribute to healthy lives, communities and environments.38,39 However, annual ‘Health Check’ reports on the strategy state that there has not yet been enough done to encourage and value innovation in health for sustainability and social value. Quality care, fair access and ‘supporting the marginalised’ are noted as factors that could be improved through a sustainable health system, but achieving health equity is not highlighted as a particular goal.38,39

Kaiser Permanente in the US has an environmental stewardship programme with goals including climate action, sustainable food and waste reduction. This is seen to be an integral part of their approach to emphasise the social, environmental, behavioural and clinical aspects that shape wellbeing.40 Benefits to ‘minority’ health are mentioned, for example, that procurement of local food is both environmentally sustainable and supports small, minority-owned businesses.41 Kaiser Permanente also recognises that its environmental actions contribute to reducing those health inequities in the US that arise from the higher exposure of Indigenous and other marginalised populations to health-harming pollution and environmental toxins in living and working environments, compared to ‘white’ populations.42

In less developed countries, the relationship between the environmental performance of health organisations and increasing the resilience of local communities (who suffer considerable health inequities compared with people in developed countries) is well recognised. Improvement to energy, water and other infrastructure at Georgetown Hospital in the Caribbean as part of a World Health Organization ‘Smart Hospitals’ initiative in the Americas was noted to not only improve environmental performance (eg, a 60% reduction in energy use); but also resulted in better access and use of the health organisation by the local community; and full functionality following a severe storm in 2013 (which crippled other health services in the area). At that time, the hospital was also able to provide safe drinking water to the storm-affected community from its rain-water harvesting system.43

A vision for pro-equity climate change and environmental sustainability action by DHBs

Given the very few specific examples in the literature regarding the deliberate pairing of climate change and environmental sustainability action in health systems with health equity, we undertook a blue-sky visioning exercise to generate ideas for pro-equity initiatives by DHBs. Blue-sky thinking is defined as ‘creative ideas that are not limited by current thinking or beliefs’.44 The exercise was based on knowledge of GHG reduction and environmental sustainability initiatives occurring both internationally as prior discussed, and within DHBs in Aotearoa/New Zealand,45 and was further informed by presentation and feedback discussion at the 2016 Annual Scientific Meeting of the New Zealand College of Public Health Medicine. Rather than proposing that this method generates high-level evidence, we argue that the blue-sky visioning exercise is grounded within the current context of climate change and environmental sustainability activity occurring within DHBs, and the considerable evidence around the urgent need for pro-equity thinking within the health and disability sector in Aotearoa/New Zealand.46

Three DHB pro-equity GHG emission reduction scenarios are envisioned in the areas of energy use, transport and procurement which, according to NHS England analysis, are the biggest contributors to the GHG/carbon footprint of the health system in England.15,47

Pro-equity DHB GHG Emissions Reduction Scenario 1

DHB One implements a sustainable energy management plan with support from the Energy Efficiency Conservation Authority (EECA). This involves a lighting retrofit (LED and motion sensors) in hospital buildings, solar panels on the renal dialysis unit (which uses large amounts of electricity during daylight hours), computer sleep-mode across the hospital campus, and modernising the heating, ventilation and cooling (HVAC) systems, including replacing the hospital coal boiler with a biomass boiler. The ongoing annual energy cost-savings are re-invested into collaborative community projects that create healthy, warm, energy-efficient homes in communities with a high proportion of Māori and Pacific peoples. Together with local council funding, and support from local Iwi and the Whānau Ora Collective, this allows a number of homes to be weather-proofed, retrofitted with insulation, double glazed and provided with heat pumps and ventilation. Working with the Whānau Ora Collective means that participating whānau are supported to access social and other services that address further determinants of health. Pre- and post-monitoring of avoidable hospital admissions related to poor-quality housing shows reduced hospital admissions for Māori and Pacific peoples in the intervention areas.

Pro-equity DHB GHG Emissions Reduction Scenario 2

DHB Two implements a sustainable travel management plan for staff travel to a regional hospital that is 100km distant from the base hospital. Outpatient clinic starting and finishing times are harmonised, a ‘book a seat’ (instead of book a car) system is established, and a number of electric vehicles are introduced in place of petrol vehicles when the DHB fleet contract is renewed. Savings from fuel and car maintenance costs are reinvested into a tailored outreach service that improves access to care for a rural, predominantly Māori community. This service, designed and developed in partnership with the local community and Māori Health Provider, involves a shuttle service for first specialist appointments and a telemedicine service for follow-up appointments located in the Māori Health Provider clinic. Monitoring of Ambulatory Sensitive Hospitalisations (ASH) by ethnicity demonstrate a reduction in adult Māori ASH rates in the community following the initiative.

Pro-equity DHB GHG Emissions Reduction Scenario 3

DHB Three implements an environmentally sustainable food plan. A policy is put in place that 80% of fresh food (eg, fruit, vegetables) in the hospital will be procured from the local region—thus reducing food-mile GHG emissions, as well as supporting local employment and income opportunities within the local food economy. Furthermore, working in partnership with the local urban marae, DHB food waste is collected and composted, then used in the marae community food garden. This reduces GHG emissions from food waste and supports food security for the wider community by harnessing and supporting knowledge on Indigenous food sovereignty and food production. As part of the policy, the DHB commits to being a purchaser of the food produced by the marae garden, thus supporting Māori economic development.

Pro-equity DHB climate change and environmental sustainability action and resilience

Pro-equity sustainability interventions have the potential to enhance the resilience of populations who will face significant climate-health impacts. Māori and Pacific peoples, children and young people, the elderly and those on low incomes are more vulnerable to the health impacts of climate change. This is not only because of existing health inequities, but because of other vulnerability factors such as poorer infrastructure (eg, housing, safe water supplies) and less financial resource to respond to damaging climate change-related events (eg, flood damage to homes with health implications related to cold temperatures, damp and mould).8–9

The reinvestment of energy cost-savings into improving community housing (Scenario 1) has the potential to not only improve health, but also means that the occupants would be more able to cope with future extreme weather events (eg, storms, heat waves) that could otherwise create a health risk. Reinvested savings from reduced DHB transport costs into a tailored outreach service (Scenario 2) contributes to the reduction of Māori health inequities, thus increasing community resilience for a population group that already bears the disproportionate burden of ill-health. Scenario 3 supports Indigenous food sovereignty and local food production. This would enhance the resilience of the community to future climate-change related changes in food systems (eg, food price spikes as food growing areas globally are affected by climate change).48,49

Is this vision realistic?

While these scenarios were generated via a ‘blue-sky thinking’ process, it is important to note that it is situated within concrete knowledge of what is already happening within health organisations within Aotearoa/New Zealand and overseas. For example, some DHBs have already made use of EECA loans and support to bring about six-figure annual energy savings which are available for reinvestment by DHBs.50 Indigenous food sovereignty is acknowledged as having considerable potential to promote to health, wellbeing, resilience and environmental sustainability.51,52

We acknowledge however that there are limitations. The visioning aims to outline in broad brushstrokes what might be possible if DHB climate change and environmental sustainability action are deliberately pro-equity, in order to avoid the real risk of the worsening of health inequities if they are not. The scenarios have not been costed; and the real-world challenges and barriers that are present within all large health organisations have not been explored. On the other hand, tackling complex challenges may well require, at least as a starting point, the type of unconstrained ‘outside the box’ thinking that blue-sky visioning encourages.

What we need to move forward

For these DHB pro-equity climate change and environmental sustainability actions to become a reality we need the Government and the Ministry of Health to follow up on their health equity and GHG reduction directives to DHBs with some concrete actions, for example:

  • Directing DHBs to keep equity at the centre of climate change and environmental sustainability action, and ensuring partnership with Māori at every level in the planning, implementation, monitoring and reporting processes.
  • Establishing a national ‘Sustainable Development Unit’ for the health and disability sector, and the establishment of sustainability managers with expertise in health equity in each DHB, so that existing action can be coordinated and a pro-equity lens consistently applied to all initiatives.
  • Mandating that all DHBs measure, reduce and report annually on their GHG emissions in accordance with the International Organization for Standardization (ISO) standard, and that as part of the annual reporting there is:
  • Specific reporting on how GHG emission reduction actions have contributed toward the reduction of health inequities for Māori and Pacific peoples.


Unsustainable development, inequity and ill-health are all interlinked,53 and any comprehensive plan for better health and wellbeing for all peoples must take these interconnections into account.

Too often new health priorities and programmes are implemented without sufficient thought to their potential to worsen health inequities; and the climate change and environmental sustainability impacts of our health and disability sector have until recently been largely overlooked.

We argue that current ministerial directives to address both health inequities and DHB GHG emissions present an opportunity for the health and disability sector to systematically address both priorities at the same time. In doing so, Aotearoa/New Zealand has the potential to lead the world in demonstrating pro-equity health system climate change and environmental sustainability action.


As outlined in the 2018 ‘Letter of Expectations’ from the Minister of Health, climate change action is now expected of DHBs. We argue that this - and all other - DHB action must be pro-equity to achieve fair health outcomes for Māori and Pacific populations. Three scenarios are proposed in the areas of DHB energy use, transport and purchasing where climate pollution could be reduced, and health determinants and outcomes for Māori and Pacific peoples improved. The scenarios show that by taking a sustainability and equity perspective, it is possible for DHBs to move beyond disease treatment to create health and equity solutions.



With current health ministerial directives to prioritise actions on reducing health inequities and district health board (DHB) greenhouse gas (GHG) emissions, we argue that all climate change and environmental sustainability actions by DHBs must be pro-equity, and explore how the two priorities can be addressed concurrently.


Building on prior knowledge of climate change and environmental sustainability action in the health and disability sector, we undertook a visioning exercise to generate ideas for pro-equity GHG emissions reduction initiatives in the DHB context. Visioning was further informed by presentation and feedback discussion at an Annual Scientific Meeting of the New Zealand College of Public Health Medicine.


Three scenarios were envisioned in the areas of DHB energy use, transport and procurement where GHG emissions could be reduced, and health determinants and outcomes for Māori and Pacific peoples improved.


Current ministerial directives to address both health inequities and DHB greenhouse gas emissions present DHBs with the opportunity to ensure they systematically address both priorities at the same time. In doing so, Aotearoa/New Zealand has the potential to lead the world in demonstrating pro-equity climate change and sustainability action in health systems.

Author Information

Hayley Bennett, Public Health Physician, Rotorua; Paula King, Public Health Physician/Research Fellow, Te Rōpū Rangahau Hauora A Eru Pōmare (Eru Pōmare Māori Health Research Unit), University of Otago, Wellington.


Dr Hayley Bennett, Public Health Physician, Rotorua.

Correspondence Email


Competing Interests

Both authors are members of OraTaiao: The NZ Climate and Health Council. Dr Bennett is a member of the Sustainable Health Sector National Network NZ.


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