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National health system carbon footprint assessment in Spain

meeting poster© Ministerio de Sanidad

Leer el estudio de caso en español

Country context

Climate change is responsible for a wide range of impacts in Spain, affecting the environment, human health, and the economic sector.

Terrestrial and marine ecosystems are at risk. Desertification is a major concern, especially since the quality of the soils we depend on is determined by vegetation cover, rainfall, and irrigation water.1 In addition, extreme droughts and floods are becoming more frequent in our territory,2 impacting agricultural production as well as the quality and safety of the food we consume. The oceans are warming, leading to physiochemical variations that affect dissolved oxygen levels (among other impacts) and result in ecosystem changes that impact the fisheries on which we depend. These factors have a direct impact on public health.3

Concurrently, health threats resulting from temperature and precipitation variations, such as heat and cold waves, are determinant factors that increase morbidity and mortality among vulnerable and general populations due to circulatory and respiratory causes. Air pollution reduces air quality, leading to increased hospitalization, morbidity and mortality from various diseases.4 Drinking and bathing water systems are impacted by climate change, affecting the quality of services as required by law. Likewise, increasing temperatures make some regions more suitable for the proliferation of new disease vectors, favouring exposure to diseases which were previously uncommon.5

For this reason, Spain has committed to gradually reduce fossil fuels, develop a mitigation plan, and reduce greenhouse gas (GHG) emissions by 45% by 2030 with the aim of achieving net zero emissions by 2050, as agreed at COP26 in Glasgow. These commitments are supported by initiatives such as the Alliance for Transformative Action on Climate and Health (ATACH) to build climate resilient health systems and reduce emissions. Commitments derived from Dubai COP28 have equal priority, such as the abandonment of fossil fuels , climate funding for vulnerable states, as well as linking climate action to biodiversity conservation.


Implementation process

The fight against climate change has led to a wide range of strategies and actions in Spain, of which the Strategic Health and Environment Plan6 (PESMA), in collaboration with the Ministry for the Ecological Transition and the Demographic Challenge, deserves special mention due to its influence. This integrated tool presents the main actions to reduce the impact of the main environmental factors on health.

The mission and overall objective of the PESMA is to reduce the health risks arising from environmental factors and their determinants, while decreasing the burden of disease caused by these, identifying new threats and facilitating the development of environmental health policies. Its execution is framed by the Public Health Strategy on the General Law 33/2011 of Public Health, the 43rd article of the Spanish Constitution and international commitments such as the Sustainable Development Agenda 2030, the Sustainable Development Goals, and commitments to the European Union and WHO on environmental health matters.

In order to achieve the PESMA objectives, the 1st Action Programme 2022-20237 was developed. It included several actions to fight climate risks, and highlighted the pilot study on the carbon footprint of the health system. The aim of this pilot study was to determine the health system's contribution to greenhouse gas emissions and implement a reduction plan with the aim of achieving climate neutrality.

On September 2023, under the Spanish Presidency of the Council of the European Union, a high-level meeting was held at the Reina Sofia University General Hospital in Murcia. This debate forum on the health sector's contribution to climate change brought together a wide range of national and international authorities, as well as, environmental and sustainability experts. The theme was “Repercussion of the health sector on climate change: Carbon footprint in health centres”.

Among others, one of the 1st Action Programme 2022-2023 lines of action develops the national health system carbon footprint study, aiming to reduce morbidity and mortality. It is based on the knowledge of consumption and emissions of health centres to measure the carbon footprint. The 2nd Action Program 2024-2025 addresses the National Plan for reducing the carbon footprint of health care centres.

© Ministerio de Sanidad


Pilot study

The study of the carbon footprint of the health sector started with a bibliographic review of the calculation tools made available by administrations, national and international organizations. Special mention was made of the calculators of the Ministry for Ecological Transition and Demographic Challenge, the U.S. Environmental Protection Agency and the United Nations Organization. Finally, the ScopeCO2 tool of the Ecology and Develop Foundation (ECODES) was selected for its focus on health care.8

Then, the scope of the assessment was defined considering the composition of the Spanish health sector. It was decided to initiate the pilot with the health care centres included in the National Catalogue of Hospitals and to continue with primary health care centres, pharmacies, veterinary centres, etc.

An initial carbon footprint measurement was then carried out. Data were collected through an online survey divided into three scopes. The calculation of scope 1 and 2 was mandatory and the calculation of scope 3 was highly recommended. Scope 1 comprises fossil fuel consumption of stationary facilities and owned vehicles, as well as fire extinguishing, refrigerant and anaesthetic gases. Scope 2 comprises the consumption of electrical energy, the emissions of which depends on their origin. For scope 3, it is recommended to consider at least the consumption of paper, water and the generation of waste.

It was necessary to strengthen the knowledge on carbon footprinting due to the diversity of profiles of the personnel designated by the health centers for the project. In order to bring all participants together, various workshops were organised in coordination with the Ministry of Health and ECODES. Beginner and medium level workshops were developed, the latter addressing the resolution of doubts and suggestions for improvement.

An online survey was then sent to the health centres listed in the Hospitals National Catalogue In 2022. 832 health centres, both public and private, were registered, of which 210 completed the survey. This represents a participation rate of 35.5%, which allowed a preliminary analysis to be carried out. Among the questionnaires received, some were not completed or inadequately completed, resulting in a non-harmonized sample. For this reason, a non-parametric Kruskal-Wallis analysis was carried out for this early phase of the project.9,10  The results showed that the null hypothesis was rejected and there is a relation between the hospital size in terms of number of beds  and GHG emissions.

Preliminary results

Hospitals of over 500 beds were found to be responsible for 39% of GHG emissions, whereas hospitals with up to 200 beds contribute 60% of Scope 2 emissions. This may be due to the fact that hospitals with more than 500 beds are likely to benefit from energy efficiency strategies due to electricity consumption. On the other hand, the importance of paper and water consumption, as well as waste generation emissions, was highlighted. More than 42% of the Spanish health centers in this pilot study count on renewable energy producing electricity. This means an estimated saving of 153.000 tons of CO2eq from the atmosphere.

Currently, an information system is being developed by the Ministry of Health to enable the registration and consultation of carbon footprint data from members of the National Catalogue of Hospitals.


Lessons learned

Carrying out such a  project requires commitment, communication and cooperation from different administrations, both private and public, as well as awareness raising and environmental values.


A wide range of challenges have been confronted:

  • Multidisciplinary profiles: Not all participants had environmental experience and knowledge.
  • Data collection: The data were in different formats and owned by different departments.
  • Registration process: Establishing an efficient process for data collection and communication was more challenging.
  • Addressing Scope 3 emissions: Aspects outside the direct scope of the organization are more difficult to assess, particularly related to: employee commuting, business travel and supply chain related to health dimensions.

Success factors

  • Carbon footprint calculator specific for healthcare: the choice of a calculation tool oriented towards the health sector facilitated its implementation and use.
  • Training workshops and communication channels: A success factor is the creation of a support network for training and monitoring progress of efforts, combined with effective communication channels under the banner "Leaving no one behind".
  • Frequency of actions: Maintaining the periodicity of the project activities helped establish a routine workflow for the project.
  • Highlighting improvement actions: Just as it is important to identify  areas for improvement in the health system, it is also important to highlight improvement strategies or actions that help prevent or reduce greenhouse gas emissions, such as those related to renewable energy, use of natural resources or waste reduction.



The development of an integrative document that specifically emphasizes the need to propose strategies and actions on health and the environment is something that has clearly contributed to the fulfilment of commitments and objectives.

In Spain, the PESMA document identifies vulnerabilities and assesses  the relationship between health and the environment, creating a framework on which other policies, strategies and actions can be based. Through the PESMA and its action programmes, the aim is to draw up a National Plan for reducing the carbon footprint of health care centres that responds to the needs of this sector and the process of achieving climate neutrality.


Key Resources


  1. La desertificación en España. (s. f.). Ministerio Para la Transición Ecológica y el Reto Demográfico. Available at:
  2.  Preguntas habituales relacionadas con sequía y agua(FAQ). (s. f.). Ministerio Para la Transición Ecológica y el Reto Demográfico. Available at:
  3.  Sanz, M, J,. Galán, E., (2021) Impactos y Riesgos del Cambio Climático en España. Ministerio para la Transición Ecológica y el Reto Demográfico. Available at:
  4.  Subdirección General de aire Limpio y Sostenibilidad Industrial. (2023). Evaluación de la Calidad del Aire en España. Ministerio para la Transición Ecológica y el Reto Demográfico. Available at:
  5. Semenza, J. C., & Suk, J. E. (2018). Vector-borne diseases and climate change: a European perspective. FEMS microbiology letters, 365 (2), fnx244.
  6. Ministry of Health and Ministry for Ecological Transition and Demographic Challenge. (2021). Strategic Health and Environmental Plan 2022-2026. Available at:
  7. Ministry of Health and Ministry for Ecological Transition and Demographic Challenge. (2022). First Action Programme 2022-2023. Available at:
  8. ScopeCO2. Sanidad por el Clima. Available at:
  9. Kruskal-Wallis: Guo, S., Zhong, S., & Zhang, A. (2013). Privacy-preserving Kruskal-Wallis test. Computer methods and programs in biomedicine, 112 (1), 135-145. Available at:
  10. R Core Team (2021). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. Available at:
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