The current state of sustainable healthcare in Australia
Krista Verlis
A B D * , Rebecca Haddock C D and Alexandra Barratt A B D
A
B
C
D
Abstract
To provide the first document map of sustainability and decarbonisation actions across the Australian healthcare sector, as reported in publicly available documents online, and to identify gaps in actions.
Healthcare providers were identified across all state and territories. Structured Google searches between August and December 2022 were followed by document searches. Updates were undertaken, most recently in December 2023. Targeted documents included position statements, strategies, and reports. Key points from these documents pertaining to sustainability and/or decarbonisation were extracted and descriptively analysed.
A total of 294 documents were included, mostly focused on power generation, transport, building design, and circular procurement/waste pathways. In contrast, relatively few plans for decarbonisation of clinical care were identified (n = 42). National and two state governments (New South Wales, Western Australia) have established healthcare sustainability and decarbonisation units, and two further states have publicly committed to doing so (Queensland, Tasmania). However, these documents generally reported separate, siloed actions. While attempts were made to make this review comprehensive, some documents may have been missed or are only available inside an organisation, and new actions will continue to emerge.
Broad sustainability plans have been developed by many healthcare providers; however, to achieve net zero, decarbonising of clinical practices is also needed, and this is where the least action is currently occurring. To decarbonise clinical care, the sector needs to come together in a more coordinated way.
Keywords: climate change, clinical care, decarbonisation, green care, health care, health systems, hospital, low carbon, net zero.
Introduction
Healthcare is a major contributor to climate change,1 responsible for 4–5% of global greenhouse gas emissions and 7% of Australia’s carbon emissions.2 Globally, the healthcare industry is starting to act to reduce its carbon footprint,3–5 with 59 countries committed to sustainable low carbon health systems. Twenty-two of those have net zero commitments under the Alliance for Action on Climate Change and Health (ATACH) Programme (formerly COP26 Health Programme).6 However, as of 2024, the Australian Government has only recently joined the ATACH Programme7 and Australia still lags behind in responding to the climate crisis.8 By aligning Australia’s health and environmental policies, such as the National Health and Climate Strategy, with global collaboration through ATACH, the Australian Government aims to accelerate progress to achieving net zero emissions by implementing effective adaptation measures.
All Australian states and territories aim to be net zero by 2050. To meet net zero targets, the health sector must decarbonise. The majority of healthcare’s carbon footprint comes from clinical care and hospitals are carbon intensive, with the remainder of the footprint originating from buildings, water, and sanitation.9,10 To succeed, plans to reach broader environmental sustainability (herein referred to as sustainability) and specific decarbonisation goals are needed. Sustainable healthcare is the provision of care that meets the needs of the current population without jeopardising future generations' health, social and economic resources.11,12 Of note, the health of humans and the environment are inextricably linked.13
To improve our understanding of the sustainability and decarbonisation actions underway or planned, we aimed to map publicly available documents, relating to health system sustainability and decarbonisation across all Australian jurisdictions, and to identify action gaps. This mapping exercise is important to maximise efficiency of limited resources, avoid duplication, share resources, and to work in a coordinated way to achieve shared goals.
Methods
Setting
Healthcare providers were identified as: (i) Australian, state, and territory health departments or ministries; (ii) public hospitals as represented by local health services (LHS), local health networks (LHNs), local health districts (LHDs), health services (HS) and hospital and healthcare services (HHS); (iii) general practitioners as represented by primary health networks (PHNs) in all states and territories; (iv) private hospital providers; and (v) professional associations and relevant professional organisations. Member searches of the Australian Global Green and Healthy Hospital (GGHH) network were also conducted.
Searches and search terms
Google searches were undertaken between August and December 2022 using the following structure: “[name of the organisation] AND environmentally sustainable healthcare”, “[name of the organisation] AND climate change”, “[name of the organisation] AND environmental sustainability”, “[name of the organisation] AND climate change sustainability”. Thereafter, sources were monitored for new initiatives or changes with the most recent update in December 2023.
Once on the stakeholder website, searches were conducted within the website’s search engine, using the keywords of “sustainability AND health”, “climate change AND health”, “environmental sustainability AND health”, “environmental sustainability”, and “climate change” as well as using the truncated “enviro* sustain*” search. Additional searches were undertaken in South Australia (SA), Tasmania, and Australian Capital Territory (ACT) to identify annual and strategic reports due to the lack of data generated by broader searches.
Included documents
Position statements, policy documents, frameworks, strategies, reports, communiques, issue briefs, and action plans. If the website did not post the document itself, but provided a sufficiently detailed outline of, for instance, an action plan, then that was considered sufficient for inclusion. News on the provider’s website that gave updates on relevant actions being undertaken as part of an environmental sustainability plan were recorded, even if the sustainability plan was not located. Strategic documents beyond 3 years out-of-date were excluded.
Data extraction and analysis
Title, type of document, organisation, acronym, URL, and key content was collected for each document. Data extraction was conducted by one researcher and verified by a second. Key content regarding sustainability and/or decarbonisation was extracted, and each document was categorised according to whether it gave information on decarbonisation of clinical care, decarbonisation of the broader healthcare system, or if neither, then it was classified as general environmental sustainability. Data were tabulated and narratively synthesised.
Results
Sustainability initiatives
A total of 294 sustainability plans or similar documents were included (Table 1, Supplementary material Table S1 list of acronyms and Supplementary material Table S2 list of identified documents). Most focused on power generation, low carbon transport, building design and improved building codes, circular procurement, improved waste pathways, education, and leadership. Forty-two documents (14%) were decarbonisation related. Though exceptions exist, plans and actions to decarbonise healthcare were generally minimal (Table 1).
| Type of healthcare provider | No. of sustainability plans, documents, initiatives found | Example | No. of decarbonisation initiatives found | Example | |
|---|---|---|---|---|---|
| Government departments (national, state & territory) | 63 | National Health and Climate Strategy (Dept of Health and Aged Care) | 13 | Removal of desflurane from public hospitals in WA (WA Dept of Health) | |
| LHD or similar (responsible for public hospitals) | 98 | Environmental Management Plan (2020–24): South West Healthcare (Vic) | 9 | Environmental Sustainability Strategy 2021–24 (SCHHS) | |
| PHN | 3 | Climate change and population health: Implementation Plan CESPHN (NSW) | 2 | Climate and Health Strategy 2020 Northern Sydney PHN (NSW) | |
| Private hospitals | 35 | Environmental sustainability strategy 2022–25 (St John of God Health Care) | 4 | Ramsay Health Care Net Zero by 2040: Ramsay Cares Greener theatres (Ramsay Health Care) | |
| Professional associations & other organisations | 95 | Environmentally sustainable healthcare position statement (RACP) | 14 | Environmental Sustainability Audit Tool (ANZCA) |
Government initiatives (Table 2)
| State/territory | Established sustainability unit | Health sustainability and or climate risk strategy or plan(s) | Decarbonisation strategy, plan, or action(s) for clinical care | State targets (for context) | |
|---|---|---|---|---|---|
| Qld |  |  |  | Net zero by 2050 | |
| Vic | – |  | – C | Net zero by 2045 | |
| WA |  |  |  | Net zero by 2050 | |
| NSW |  |  |  | Net zero by 2050 | |
| SA | – | – A |  D | Net zero by 2050 | |
| NT | – | – B | – | Net zero by 2050 | |
| ACT | – |  |  D | Net zero by 2045 | |
| Tas | A | – |  | Net zero by 2030 | |
| National |  |  | – | Net zero by 2050 |
In December 2022, the Australian Federal Government formed the National Health Sustainability and Climate Unit within the Department of Health and Aged Care14,15 and released the National Health and Climate Strategy in December 2023.16
State and territory
NSW Health in 2022, created a Climate Risk and Net Zero (CRNZ) unit as part of a value-based healthcare approach. The CRNZ strategy seeks to reduce patient harm, save money, reduce carbon emissions, and address low-value care.17 The CRNZ specifically mentions decarbonising clinical care activities as an important component18 and established Net Zero Clinical leads.19
QLD Health is working toward a climate-ready and environmentally sustainable public health system.20 In 2020, Qld also committed to establishing an Office of Hospital Sustainability. While public information about the Office is lacking, a working group established in May 2022 provides direction and develops resources to support implementation of sustainable initiatives that reduce the carbon footprint of clinical healthcare activities21 (Supplementary material Table S3).
A blueprint for the WA health system to respond to climate change via reduced emissions and waste was developed following an inquiry into climate health.22 A sustainable health unit (SDU) was established in 2022.23 The SDU is leading and coordinating a systemwide response targeting carbon hotspots, building staff skills,24 and extending to prevention and equity, aiming to shift away from a reactive, hospital-based system.25 WA was the first Australian jurisdiction to remove the high carbon, anaesthetic gas desflurane from public hospital operating theatres.26
Strategies and plans have been developed that include environmental sustainability,27 climate change,28 and wellbeing29 with a focus on tackling climate change health impacts. A further document also considers social determinants of health as a core component of sustainability.30 Legislation to guide the health sector to reduce its carbon footprint is available,31 covering topics from carbon emissions, to water, waste, and procurement
In the context of Tasmania’s ambitious net zero target32,33 (Table 2), the Tasmanian Health Department released a framework of action (2019).34 Establishing a sustainable health unit, reducing emissions, sustainable food choices, and new delivery models, including reducing unnecessary medical tests and treatments,35 are priority areas for action.34 Climate change and health is one of eight focus areas.36
Sustainable healthcare through prevention and improved wellbeing are strategies to reduce healthcare carbon emissions.37 Additionally, SA acknowledges climate change as a determinant of health38 and utilises a health approach in all policies to sustainable healthcare. The new women and children’s hospital in Adelaide will be Australia’s first major all-electric hospital and aligns with commitments to have a 100% renewable grid by 2030.39
To meet the Government’s target of net zero emissions by 2045,40 strategies and action plans41–43 aim to embed a zero-emissions pathway. The ACT health service has six key sustainability areas: resource management; building and infrastructure; the digital health environment; workforce; partnerships and external service delivery; and procurement.41 Canberra will also have Australia’s first all-electric critical care facility.44
In 2021, NT Health launched a Sustainable Healthcare Committee that examined mitigation of the health sector’s waste and emissions, and adaptations for the impacts of climate change.45 Suggested measures focus on circularity in procurement and waste management (i.e. initiatives aimed at avoidance, reduction, reuse, and recycling), and engaging health sector employees in programs to support low waste, low emissions clinical care.45
Primary health networks
Two PHNs, Central and Eastern Sydney and Northern Sydney in NSW, made mention of environmental sustainability in strategic operations (Table 2, Table S2). Both plans include some decarbonisation of clinical care activities46,47 (Table S3). NSW specifically recognises the role of primary care in shifting to net zero.48
Public hospitals and community-based health services
The NSW Government and NSW Health are committed to net zero healthcare. They offer resources to help LHDs produce net zero plans49 and supports Net Zero Clinical Leads program in developing scalable low-carbon models of care.19 Eight LHDs published environmental sustainability plans (Tables S2, S3). For example, the Northern Sydney Local Health District plan describes an evaluation of the carbon footprint of current models of care, identifying opportunities to minimise environmental impacts.50
Climate adaption and climate risk strategy documents have been released to support HHS’ to undertake climate risk assessments and plan adaptation strategies.51 Specific HHS’ have also developed sustainability plans or frameworks, and decarbonisation actions are occurring.52,53 For example, phasing out of desflurane anaesthetic across Cairns and the Hinterlands HHS.54
In addition to ending desflurane use in all public hospitals,26 several HS in WA have sustainability plans or have environmental sustainability flagged in broader strategic plans (Tables S2, S3). The South Metropolitan Health Service environmental strategy specifically mentions sustainability and decarbonisation of clinical care and aims to be net zero 10 years before the state.55
A search of SA’s 10 LHNs, revealed two (Flinders and Upper North, and Northern Adelaide) general strategic plans with environmental sustainability as main pillars/imperatives. However, no specific environmental sustainability or decarbonisation plans were located (Table S2).
Of 75 HHS (18 metro area, 57 regional/rural), 22 were identified as having separate environmental sustainability documents with many more having sustainability initiatives noted within broader strategic plans or reports (Table S2). Due to the large number of services, it was more challenging to identify sustainability initiatives, and some may have been missed.
Private health providers
Some private hospital provider groups have environmental sustainability strategies that include aspects of decarbonised clinical care56–58 (Table 1, Tables S2, S3). Again, due to lack of publicly available information, some plans may have been missed.
Professional organisations
Most (87%) medical colleges and dental associations have policy or position statements, action plans, or other documents encouraging sustainability actions (Table 1, Table S2). Many have co-signed letters calling for action, acknowledged climate change and its impacts on human health, and/or recognised the need for education and action (Table S2). Some have created new protocols or modified existing ones to reduce waste and decarbonise their clinical practices (Table S3).
Medical colleges are well placed to lead sustainable clinical practice and to assess the carbon footprint of professional activities.59 However, a recent report noted some medical colleges and associations did not think that sustainability was relevant to them, and in one instance, viewed climate change as a social issue and not a health issue.60
Non-government organisations
Numerous peak and professional organisations are working toward engagement with policy and policy makers in developing and/or implementing sustainability strategies (Table S2).
Where to from here?
This, first ever undertaken, mapping exercise clearly shows that sustainable healthcare is supported by governments and healthcare professionals. However, not all actors are likely to be able to make decisions and/or make immediate change; neither are the resources, tools, and knowledge necessarily available across the sector for making changes, particularly towards decarbonisation of healthcare. Therefore, advocacy by peak health and climate groups continues to be important to drive further action.
Of note, evaluation data on the outcomes of sustainability activities were lacking and are needed to track progress and improve environmental performance. Action within the private healthcare sector must be encouraged, given their involvement in high greenhouse gas emission producing activities.61 Also, there is a need for increased transparency in reporting sustainability activities across the whole of the healthcare sector, ideally in a coordinated manner.
The high number of sustainability initiatives compared to actions to decarbonise clinical practice, highlights gaps in action and suggests a lack of awareness of what is required to achieve meaningful reductions in carbon emissions, and ultimately net-zero healthcare. Low-carbon clinical care and the minimisation/elimination of low-value care must be significant features of net zero healthcare.9 Primary prevention and primary care will be key to keeping community members healthy and minimise the need for carbon-intensive hospital care.62 The health in all policies approach, identified in the National Health and Climate Strategy and already favoured by several states, will be helpful in supporting primary prevention and care activities.63 Health professionals clearly have an essential role in driving change.1,59
The newly released National Health and Climate Strategy, along with the establishment of the National Health, Sustainability and Climate unit, is an important step in Australia’s pathway to sustainable healthcare. It can provide long-awaited, critical leadership and potentially national coordination. Implementation and evaluation of actions to improve the sustainability of healthcare and specifically to address decarbonised clinical care will be important next steps.
Limitations
An inherent limitation of this exercise is the rapidly evolving nature of available information, which will continue to emerge as net zero policies are created and related strategic activities occur. In instances it was challenging to locate information, and some under-reporting may have occurred despite our efforts to be comprehensive. Contacting individual stakeholders for comment fell outside scope of this project and information at the individual hospital or service provider level has not been included. Nonetheless, our results provide a valuable first snapshot of the current landscape of healthcare sustainability and decarbonisation in Australia.
Conclusion
This mapping exercise provides a baseline snapshot of sustainability plans and action across the Australian health sector. Most sustainability plans appeared to focus upon measures such as sustainable energy, electric vehicles, improved building codes, procurement and waste pathways, education, and leadership opportunities. These are all important steps in reducing the carbon footprint of healthcare, but to achieve net zero, decarbonising of clinical practices is needed, yet this is where the least action is currently being undertaken.
The National Health, Sustainability and Climate Unit provides an opportunity for long-awaited national leadership, guidance, and resources. It can play a key role in coordinating the healthcare sector to come together under the Health and Climate Strategy to deliver low carbon, environmentally sustainable healthcare.
Data availability
The data that support this study are available in the article and accompanying online supplementary material.
Declaration of funding
Dr Verlis’ work on this project was supported by the Healthy Environments and Lives (HEAL) National Network funded by the NHMRC – Grant Number 2008937.
Acknowledgements
We thank Dr Christopher Kocx for his work verifying the data extracted from the source documents. We also acknowledge the HEAL (Healthy Environments And Lives) National Research Network, which receives funding from the National Health and Medical Research Council (NHMRC) Special Initiative in Human Health and Environmental Change (Grant No. 2008937).
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