European Heath Care Systems (HCSs) face increasing climate-related pressures. Heatwaves, floods, wildfires and air pollution increase HC demand, especially for cardiovascular, respiratory and heat-related conditions, while also disrupting service delivery and infrastructure. At the same time, the HC sector contributes substantially to environmental degradation, accounting for ~5% of greenhouse gas emissions, driven by energy-intensive facilities and resource-intensive care pathways. This creates a cycle of harm, where HCSs both contribute to and are affected by climate change. Breaking this cycle requires a system-wide shift towards sustainable and climate-resilient performance as a core part of governance and decision-making

Current approaches do not provide policymakers and HCS leaders with integrated, system-level performance intelligence. This makes it difficult to balance environmental sustainability, climate resilience and core HCS goals such as quality, access, equity, efficiency and financial sustainability. As a result, decision-making remains partial and siloed. In addition, limited attention to behavioural, organisational and governance factors reduces effective implementation and scale‑up of complex climate and health interventions. In practice, systems often focus on visible but low-impact actions system pressures and environmental impact through integrated mitigation and such as recycling, while more impactful areas such as adaptation strategies, generating co-benefits for health and climate. infrastructure, clinical decision-making, procurement and system organisation, remain underused. This creates misalignment with core HCS goals.

HCSs are expected to achieve multiple goals at the same time, but these are not assessed together. This limits learning, and coordinated, effective, and efficient system steering and increases the risk of unintended consequences when trade-offs are not carefully considered.