In 2023, fifteen countries spent more on net fossil fuel subsidies than on their entire national health budgets. That finding comes from the 2025 report of the Lancet Countdown on health and climate change, published at the end of October. The same governments that tell hospitals to find efficiency savings are paying to keep the fuel cheap that fills those hospitals with asthma, heat stroke and cardiac arrest.
That is the argument in one sentence. Climate policy is already health policy. The trouble is that health ministries mostly act as if it belongs to someone else.
The bill is already arriving at the emergency department
The Lancet Countdown puts heat-related deaths at an average of 546,000 a year over 2012 to 2021, well above the level of the 1990s. It attributes about 2.5 million deaths a year to air pollution from burning fossil fuels. These are not projections for 2050. They are current deaths, and they show up as admissions, bed days and overtime.
Then there is the infrastructure. When floods hit Pakistan in 2022, WHO reported within the first weeks that more than 1,460 health facilities had been affected, 432 of them fully damaged. National disaster authorities later put the figure at around 2,000, roughly a tenth of the country’s facilities. A clinic that is under water cannot deliver the vaccination campaign that the health plan budgeted for.
Most health professionals know some version of these numbers. What gets less attention is who controls the levers that would change them. Mostly, it is not the health ministry.
The uncomfortable part: health gets the costs, others own the decisions
Energy ministries set fuel subsidies. Transport ministries decide whether a city builds bus lanes or flyovers. Urban planners decide whether a new housing block gets shade trees or a car park. Finance ministries decide all of it.
Health ministries, meanwhile, receive the invoice. They pay for the extra admissions during a heatwave. They absorb the cost of the dialysis patient who could not reach the unit during a flood. They are, in effect, the insurer of last resort for decisions made elsewhere, with no seat at the underwriting table.
This is the incentive problem underneath the slogan. A health minister who argues against a fuel subsidy is picking a fight with a stronger ministry over a budget line that is not theirs, to prevent costs that will land years later on someone else’s watch. The rational career move is to stay quiet and ask for a bigger hospital budget. So they do.
The fix is not more awareness. It is institutional: health impact assessment built into energy, transport and housing decisions, with the health ministry holding the pen on the numbers. That is dull, bureaucratic work, and it is where the leverage is.
Stop leading with the hospital’s carbon footprint
The conventional health-sector response to climate change has been to look inward. Health care produces about 4.4% of global net emissions, according to Health Care Without Harm’s widely cited estimate. If the sector were a country, it would be among the largest emitters on the planet. England’s NHS became the first national health system to commit to net zero, in 2020, with a 2040 target for the emissions it controls directly.
That work matters, and nobody should stop doing it. But a strategy that starts and ends with anaesthetic gases and hospital boilers misses the bigger prize. Decarbonising the entire health sector would, by definition, touch less than a twentieth of the problem. Getting health evidence into the energy and transport decisions that drive the other 95% is worth far more.
There is also a framing trap. When the health sector talks mainly about its own footprint, it presents itself as part of the problem asking for permission to spend on solar panels. When it talks about avoidable deaths from air pollution and heat, it is the only ministry in the room that can put a human cost on a policy choice. That is a much stronger negotiating position.
Adaptation is cheaper than people assume
Some of the most effective climate-health measures are almost embarrassingly low-tech.
Ahmedabad, in western India, launched South Asia’s first heat action plan in 2013 after a deadly heatwave in 2010. It combined early warnings, public messaging, training for health workers and changes to hospital preparedness. An evaluation published in the Journal of Environmental and Public Health in 2018 estimated an average of about 1,190 deaths avoided per year in the two summers after the plan took effect, compared with a baseline period. Mortality on the very hottest days fell most.
No new hospital. No new drug. Mostly coordination between the municipal corporation, the meteorological department and the health system.
This is the point health leaders undersell. Heat plans, flood-resilient cold chains, surveillance that links weather data to disease alerts: these are health-system functions, cheap relative to what they prevent, and squarely within a health ministry’s own authority. They are also the credibility health leaders need before they can argue with the finance ministry about subsidies.
What health leaders could actually do
A few practical shifts, none of them glamorous:
- Quantify the cost you are absorbing. Heat and pollution admissions, by district and by season, in money as well as lives. Finance ministries respond to budget lines, not moral appeals.
- Ask for a formal role in energy and transport decisions. Health impact assessment should be a required step, not an invitation extended when convenient.
- Fund adaptation as core service delivery. Heat action plans and flood-proof supply chains belong in the operating budget, not in a donor-funded climate project that ends in three years.
- Keep decarbonising, but don’t let it be the whole story. The footprint work earns credibility. It is not the main event.
A worked scenario: one heatwave, three budgets
Picture a mid-sized city in a hot, fast-growing country during a week of extreme heat.
The health ministry sees it first. Emergency departments fill with older people who are dehydrated, confused or in heart failure. Outdoor workers arrive with heat exhaustion. Admissions for kidney injury rise. Some hospitals, in older buildings without adequate cooling, find that their own wards become dangerous for frail patients. Staff work double shifts in the same heat. The extra spending comes out of this year’s health budget, which was not written with a heatwave in mind.
The energy ministry sees something else: record electricity demand as air conditioners run flat out, and pressure to keep power cheap and uninterrupted. Its immediate incentive is to protect supply at almost any cost, including by burning more of the cheapest, dirtiest fuel available.
The urban development authority sees nothing at all during the week itself. But its decisions over the previous decade, how much green space was kept, whether new housing was designed for ventilation and shade, how dense and paved the poorest neighbourhoods became, determined how hot those neighbourhoods got and who lived in them.
Three budgets, three sets of decisions, one set of patients. Only one of those budgets pays for the admissions. That is the structural problem in miniature, and it recurs in almost every climate-health interaction, from flooding to air pollution to vector-borne disease moving into new areas.
The strongest counterargument
A fair objection runs like this. Health ministries are already overstretched. They struggle to deliver primary care, manage workforce shortages and keep medicines in stock. Asking them to take on energy, transport and urban policy is a recipe for doing everything badly. Better to stay in their lane, deliver care well and let climate policy be run by those who hold the levers.
This argument partly holds. A health ministry that tries to become a climate ministry will fail at both. And there is a real risk that climate becomes a fashionable distraction from unglamorous core business.
But the objection confuses doing with informing. The ask is not that health ministries run the energy sector. It is that they bring evidence of health costs into decisions that others make, and that they build the adaptation functions, such as heat-health warnings and resilient supply chains, that are already squarely theirs. Neither requires a new empire. Both require a small, capable team that can quantify health impacts and a formal channel for putting those numbers in front of decision-makers.
There is also a practical reason to engage. Fuel subsidy reform, when it happens, is politically dangerous. Governments that attempt it often reverse course after protests. Health arguments, especially about children’s air quality and deaths in heatwaves, can be among the more persuasive ones for the public. A health ministry that has done its homework can make reform easier, not just more virtuous.
What this means for different players
Ministries of health need a small analytical unit that can estimate the health costs of energy, transport and housing decisions in the ministry’s own data. Without it, health arguments remain generic appeals that other ministries can safely ignore.
Finance ministries should see health-cost evidence as a fiscal tool. When a subsidy costs more in health spending and lost productivity than it saves consumers, that is a budget argument, not only an environmental one.
Hospital leaders should treat heat and flood preparedness as clinical risk management. That means knowing which wards overheat, which supply routes flood, and which patients, such as those on dialysis or oxygen, are most vulnerable when services are interrupted.
Funders should be sceptical of climate-health projects that end when the grant ends. Heat action plans and surveillance systems need recurrent funding in national budgets to survive. A funder’s most useful contribution may be helping a ministry build the evidence that wins that budget line.
Clinicians have a role that is often underestimated. Doctors and nurses are among the most trusted voices in most societies. When they explain the health consequences of air pollution or extreme heat, in public and to policymakers, they can shift the political calculus in a way that reports alone rarely do.
What to watch next
A few signals will show whether health is gaining real influence over climate decisions. Watch whether finance ministries begin publishing health-cost estimates alongside energy subsidy budgets. Watch whether national heat-health action plans move from pilot cities to national programmes with their own budget lines. And watch whether health ministries appear as formal participants, rather than guests, in national climate planning and in the country commitments submitted under the Paris Agreement.
Watch, too, whether hospitals begin reporting heat-related admissions as a routine indicator, the way they report infection rates. What gets counted in the health system’s own dashboards tends to get managed.
The direction of those signals will say more about the future of climate and health than any single global report.
The takeaway
Health systems are already paying for climate policy. They are just paying without a vote. The question for health leaders is not whether climate belongs on their agenda, since it arrived there on its own. It is whether they are willing to spend political capital in rooms where they have historically been guests.
A ministry that only counts its own emissions is managing its reputation. A ministry that counts the admissions caused by someone else’s subsidy is doing health policy.
Has your health system ever put a price on climate-related admissions and taken that number to another ministry? We’d like to hear how it went.
