The scoping review sought to include studies reporting health facility interventions and adaptation strategies targeted at strengthening facility resilience against climate-related health risks or mitigating the impacts of climate change. The studies must have been conducted within health facility settings involving either patients, health facility staff or any quality improvement interventions targeting any component of health facilities. As such, non-patient populations, outdoor workers or interventions targeting individuals living in communities were excluded unless it included those who accessed services at the respective facilities. In addition, we excluded studies that only evaluated the impacts of climate change without focusing on specific interventions applied. The review only included studies conducted in low- and middle-income countries as defined by the World Bank (Supplementary information 1: search Strategy)

A narrative synthesis, involving both quantitative and qualitative approaches, was employed to summarize and report the results from the selected studies following the methodological framework provided by Arksey and O’Malley [14]. We first performed numerical analyses to describe the characteristics of the included studies including their geographical distribution, study designs, study population and interventions. Thematic analysis was then used for in-depth synthesis of findings of the included studies allowing for cross-study comparisons. The results were reported using tables and figures and complemented with the narrative description of the key themes emerging from the synthesis.

Figure 3 presents the WHO conceptual framework for building climate-resilient health systems, which was used to guide the analytical lens for this review [25]. The framework outlines ten core components including leadership and governance; health workforce; climate and health risk and vulnerability assessment; integrated risk monitoring and early warning; health and climate research; climate-resilient and low-carbon health care facilities and technologies; management of environmental determinants of health; climate-informed health programmes; emergency preparedness and disaster risk management for health; and climate and health financing [25]. In the sections that follow, we first present the results of our synthesis (Table 1 and Supplementary Table 1) and then compare these findings against the WHO framework (Fig. 4) in the discussion section to identify areas of alignment, implementation, and remaining system level gaps.

Table 1 presents the main climate related adaptation themes identified from the review. Four overarching themes emerged: (1) capacity building; (2) structural adaptation and facility preparedness; (3) water, sanitation and hygiene (WASH) and emergency response beyond health facilities; and (4) barriers and challenges (Table 1).

1. Capacity Building for Climate Related Health Preparedness

Our review found that capacity building interventions targeted both health workers and the communities they serve. Structured training programmes strengthened technical competencies and decision-making capacity for climate-related emergencies. In Vietnam, Minh et al. (2014) incorporated disaster simulation drills, first aid and emergency care training, and pre-season readiness activities that equipped health workers and village health teams for storm and flood events. Mishra et al. (2025) also reported training initiatives for staff and resident doctors to manage seasonal climate related surges, including those linked to storm-associated disease patterns. In Pakistan, Khan et al. (2023) demonstrated that the HEAT educational programme, which included workshops, simulation exercises, wall-mounted algorithms, and pocket-sized clinical manuals, improved diagnostic accuracy for heat-related conditions and increased the use of appropriate cooling techniques in emergency departments.

Several interventions extended beyond health facilities to build preparedness at the community level. Minh et al. (2014) delivered education on hygiene, water safety, first aid, and storm-related risks, strengthening household preparedness and supporting more effective community responses during storms and floods. Araban et al. (2017) implemented a behavioural education programme for pregnant women that improved preventive behaviours and self-efficacy in reducing exposure to air pollution through motivational interviewing, educational materials, and daily SMS alerts. Mishra et al. (2025) introduced WASH-related behavioural supports, including sanitary stations and hygiene-promotion materials, which improved community water safety but were constrained by maintenance requirements and limited resources. Minh et al. (2014) additionally reported challenges in sustaining community engagement with water safety messaging.

2. Health Facility Preparedness, Structural Adaptation, and Low-Carbon System Resilience

Our findings reveal that facilities are adopting combined infrastructural, technological, and energy-efficiency strategies to enhance climate resilience while reducing operational vulnerabilities. Five studies reported interventions aimed at strengthening facility preparedness and structural resilience to climate-related hazards, including heat, storms, pollution, and energy instability [16, 17, 21, 23, 24]. Facilities undertook spatial and infrastructural modifications to protect patients and ensure service continuity under extreme conditions. In India, Kakkad et al. (2014) demonstrated how relocating neonatal wards from the overheated fourth floor to the cooler ground floor reduced heat-related neonatal morbidity. In South Africa, Naidoo et al. (2022) highlighted rapid spatial and operational reconfigurations during flooding, enabling facilities to continue providing essential care despite environmental disruption. Alok et al. (2025) strengthened infrastructural capacity through extended operating hours, expanded staffing, and improvements to supply chains and outreach systems, supporting ongoing care in resource-limited, climate-sensitive settings. An (2025) showed how optimised air purifier placement within clinical wards reduced particulate exposure for vulnerable patients. Integrated within this broader structural adaptation agenda were sustainability and low-carbon initiatives aimed at improving energy security and reducing environmental impact. Mishra et al. (2025) reported installation of solar panels, energy-efficient lighting, and conservation practices alongside reverse-osmosis systems to ensure clean water, contributing to both resilience and reduced emissions, though implementation was limited by cost and maintenance requirements. Similarly, Amadi et al. (2025) demonstrated how a solar-powered neonatal device expanded access to essential care in remote, off-grid settings.

3. WASH Improvements and Emergency Response Measures beyond Health facilities

Although the primary focus of this review was on facility-level interventions, we found that several facilities implemented actions that extended beyond the facilities into the communities they serve. For example, Minh et al. (2014) delivered ongoing community education on hygiene, water safety, first aid, and storm-related risks, which helped strengthen household preparedness and supported more effective community-level response during storms and floods. Similarly, Araban et al. (2017) implemented a behavioural education programme for pregnant women including motivational interviewing, educational materials, and daily SMS alerts which improved preventive behaviours and self-efficacy in reducing exposure to air pollution. Interventions related to water and sanitation resilience were reported in two studies. Mishra et al. (2025) described the installation of reverse-osmosis systems, sanitary stations, and WASH-related behavioural supports, which improved water safety but were constrained by maintenance demands and limited resources. Minh et al. (2014) implemented community-oriented water safety activities, including hygiene education and preparedness messaging, which helped reduce contamination risks during storms and floods, however community outreach was challenged. Emergency preparedness and disaster response measures were identified in four studies. Besides strengthened WASH system, Mishra et al. (2025) highlighted essential medicine stocks, and staff training and. Minh et al. (2014) reported structured pre-season planning, disaster simulation drills, and emergency kit stocking that enhanced storm and flood readiness. Naidoo et al. (2022) documented rapid operational adjustments during flooding, including staff redeployment, extended service hours, and mobile outreach to maintain essential care. De Almeida et al. (2021) described activation of a hospital disaster plan that facilitated coordinated task-sharing, flexible staff deployment, and prioritisation of emergency services during a surge in trauma cases.

4. Barriers and challenges

The review found that structural and systems level barriers such as damaged infrastructure, unreliable power, and inadequate WASH and ventilation systems disrupted service delivery in South Africa [16], Vietnam [22], and Nepal [19]. In India, neonatal wards located on the hottest floor exacerbated heat vulnerability before relocation [23], while older hospital buildings in Korea reduced the efficacy of air-purification interventions [21]. Weak governance and planning such as the absence of early warning systems, unclear roles, fragmented coordination, and insufficient funding constrained preparedness across South Africa, Vietnam, and India [16, 22, 24]. Resource shortages, including a lack of supplies, inconsistent stock, and limited equipment, were commonly reported, with financial constraints preventing expanded trials of climate-responsive technologies in Nigeria [15].

The review also established that the workforce, behavioural, and contextual barriers shaped the uptake of climate adaptation measures. Several studies reported insufficient training, uneven staff capacity, and heavy workloads as impediments to implementing emergency practices, particularly in Pakistan’s emergency departments [20] and in Vietnam’s primary care system [22]. Emotional stress and staff fatigue further constrained response efforts during the Nepal earthquake [19]. At the community level, behavioural recommendations sometimes conflicted with daily responsibilities, limiting adherence among pregnant women in Iran [18]. In Haiti and India, incomplete clinical data and lack of disease coding hindered accurate assessment of climate-sensitive conditions [17, 23].

Figure 4 presents how the included studies in this review align with the pillars of the WHO framework, highlighting the gaps in evidence across dimensions.

As illustrated in the results and Fig. 4, most documented interventions cluster around three domains: climate-smart health workforce development [20, 22, 24], climate-related emergency preparedness and management [16, 19, 22, 24], and climate-resilient infrastructure and technologies [15, 16, 21, 23, 24]. While these interventions demonstrate efforts to strengthen resilience under worsening climate pressures, they remain highly localised, small in scale, and poorly integrated into broader system planning. Overall, the ten studies from the review shows minimal implementation of climate-resilience measures across LMIC health facilities, with adaptations tending to be reactive and facility-specific rather than embedded within coordinated, system-wide strategies.

Equally striking are the components of the WHO framework that were entirely absent. No studies addressed climate-transformative governance, sustainable climate and health financing, integrated risk monitoring or early warning systems, climate-informed health programmes, or climate and health research domains critical for long term system resilience. These omissions, coupled with structural vulnerabilities, weak governance, fragmented coordination, resource shortages, limited staff capacity, and behavioural constraints, reveal some of the systemic barriers limiting adaptation. The findings suggest that LMIC health facilities remain far from operationalising the WHO framework and highlight the need for strengthened governance, dedicated financing, integrated surveillance and early-warning capacities, and the routine incorporation of climate considerations into health system planning and service delivery.

This scoping review provides one of the first systematic examinations of climate related interventions and adaptations within health facilities in low and middle-income countries. Incorporating qualitative, quantitative, and mixed-methods studies from diverse settings, offered a comprehensive view of how facilities are responding to climate pressures in routine practice. The thematic synthesis covering capacity building, structural adaptation, WASH improvements, and system barriers provides a clear framework for interpreting heterogeneous evidence. The review also identifies important gaps in knowledge, helping to shape priorities for future research on climate resilience in health facilities.

This review is shaped by several limitations. The evidence on climate related adaptations in LMIC health facilities is still sparse and uneven, with many studies describing small, context specific interventions and offering limited outcomes or follow up. Inconsistent reporting, particularly on indoor conditions, resource constraints and implementation processes, reduced comparability across settings. Relevant studies may also have been missed because climate and health systems research is poorly indexed, especially in grey literature. Finally, as a scoping review, we did not appraise study quality, which limits the strength of any causal interpretations.