Key enablers and barriers to climate-smart primary healthcare in South Africa: Insights from climate and health experts

THANDAZILE SIBINDI , Jennifer Chipps, Talitha Crowley 

Climate change poses escalating threats to global health, with disproportionately severe impacts in low- and middle-income countries (LMIC) where structural vulnerabilities, resource constraints, and limited adaptive capacity heighten population-level risks. In these settings, primary health care (PHC), the frontline of service delivery, plays a pivotal role in implementing climate adaptation, mitigation, and resilience strategies. Yet, despite growing recognition of the need for climate-smart health systems, evidence on the enablers and barriers to climate-smart PHC remains sparse in South Africa, reflecting broader gaps across LMIC contexts. The study aimed to explore the views of climate and health experts on the enablers and barriers of climate-smart PHC in South Africa. The study was conducted across relevant local, national, and international experts in health and climate change. An exploratory qualitative design was employed, involving 15 semi-structured interviews with purposively selected experts, including nursing educators, policymakers, academics, and health managers, all of whom had demonstrated experience in climate change and health through leadership roles, policy involvement, curriculum development, or relevant research. Data were analysed using reflexive thematic analysis supported by ATLAS.ti. Four key enablers emerged: public awareness, sustainable infrastructure, professional education, and supportive policy frameworks. These enablers were viewed as essential for promoting climate-smart PHC. Conversely, major barriers included limited awareness, socio-political and structural constraints, human resource shortages, and inadequate research and training. Experts emphasised that climate-smart PHC requires integrated, multi-sectoral strategies and systemic reforms. Building a climate-smart PHC demands a whole-of-society approach that combines education, infrastructure investment, and policy coherence while addressing systemic fragilities. This study provides empirical insights into the social, structural, and policy determinants of a climate-smart PHC. This can inform strategies for workforce development and health system strengthening in LMICs.