Brazil launched a sweeping climate-health action plan on Thursday, named after the COP30 host city in the Amazon, winning initial endorsements from roughly two dozen countries for a voluntary framework calling on nations to strengthen disease surveillance, build climate-resilient infrastructure, and protect vulnerable populations from the health impacts of rising temperatures and extreme weather.

The Belém Health Action Plan outlines 60 action items across surveillance systems, evidence-based policies, and health innovation to address the health risks facing 3.3 billion people globally affected by the climate crisis.

“The climate crisis is one of the most significant health challenges of our time,” states the plan, developed by Brazil’s health ministry in consultation with the WHO. Countries that endorse the voluntary framework will report their progress through UN climate negotiations during the second Global Stocktake at COP33 in 2028.

The World Health Organization calls climate change “the greatest single risk to humanity,” and the World Bank estimates it could cause up to 15.6 million deaths between 2026 and 2050, with health impacts costing $8.6 to $15.4 trillion by mid-century.

Initial supporters include European Union states such as France and Spain, small island nations like Tuvalu, African countries from Congo to Zambia, and others including Canada, Japan, the United Kingdom and Malaysia.

Brazil’s health minister Alexandre Padilha said the plan had received backing from more than 80 nations and institutions, though the vast majority comprises civil society organisations like the Global Climate and Health Alliance, global health actors including Medicines for Malaria Venture and Drugs for Neglected Diseases Initiative, and UN agencies such as UNFPA, UNICEF and UNITAID.

“We expect to have more by the end of the day and the end of the COP,” Padilha said, adding the presidency would continue “trying to engage and mobilise” more countries. “There’s a very strong commitment from our government and ministers of health in this plan.”

The voluntary nature of the framework and broad support for the Alliance for Transformative Action on Climate and Health (ATACH) — a WHO-led initiative launched at COP26, which now counts 101 members — suggest endorsements will likely grow, but implementation remains uncertain. WHO will serve as the secretariat for the Belém plan, measuring outcomes through the ATACH framework.

The sole explicit dissent Thursday came from Egypt, part of the Baku coalition of previous COP presidencies that helped draft the plan. Egypt’s health minister expressed willingness to join but voiced “concern about the reference to the inclusion of LGBTIQ+ individuals, as such patterns fall outside the nationally recognised policy frameworks in the cultural context of Egypt.”

Other coalition members, the United Arab Emirates and Azerbaijan, expressed political will to continue discussions but stopped short of endorsement, instead noting they had “contributed” and “noted with interest” the framework’s goals.

“We have to look at the impact of climate change, one of the main threats to public health in the world today,” Padilha said. “Scientific evidence has shown clearly that the climate crisis is first and foremost a crisis of public health throughout the world.”

“The time of warnings has finished. Now we are living in a time of consequences,” he added. “The climate has already changed, so we have no alternative but to have public policies to adapt and face climate change.”

No money from nations

The launch came with no new financial commitments from endorsing nations. The sole funding announcement came from a coalition of philanthropies including the Gates Foundation, Wellcome Trust, and Rockefeller Foundation: a $300m one-time grant to support climate-health adaptation measures.

That figure is dwarfed by estimates that low- and middle-income countries require at least $11 billion annually just for basic health adaptation covering only disease control for malaria, dengue, diarrheal diseases, heat-related mortality, and essential surveillance improvements, according to the UN Environment Programme.

“Health systems, already stretched and underfunded, are struggling to cope with these growing pressures, and most are still unprepared for what is coming,” said Marina Romanello, executive director of the Lancet Countdown at University College London. “Existing finance falls short by billions. Without urgent investment, we will not be able to protect populations from escalating climate impacts.”

The $11 billion annual UNEP pricetag excludes respiratory illnesses, malnutrition, mental health services, additional infectious disease programs, workers’ health protection, supply chain adaptation, and health system decarbonisation — most of what the Belém plan contains. The UNFCCC estimates global health adaptation will require $26.8 to 29.4 billion annually by 2050.

Current health-specific climate finance reaching those countries totals perhaps $500 to $700 million annually, representing 2% of adaptation funding and 0.5% of multilateral climate finance. “With regards to finance, that reality is that we have a deficit that is quite colossal,” said Carlos Lopes, Special Envoy for Africa to the COP30 Presidency.

As temperatures continue rising and extreme weather events intensify, pressure mounts for health system adaptation at a moment when global health financing faces unprecedented strain. Overall development assistance for health dropped 21% from nearly $50 billion in 2024 to $39 billion in 2025, driven largely by US withdrawal from global health programs. The WHO itself faces budget shortfalls of 15-20%.

Climate-health financing has grown from less than $1 billion globally in 2018 to $7.1 billion in 2022, the only aid sector to grow in that time apart from education, according to Rockefeller Foundation analysis. But substantial portions arrive as loans: 24% of bilateral climate-health funding and more than 90% from the Asian Development Bank and Inter-American Development Bank.

Many developing countries now spend more on servicing debt than on healthcare, with low-income countries spending roughly 300 times less per capita on health than wealthy nations.

That finance shortfall impacts their ability to implement adaptation plans like the Belem Framework: A 2021 WHO survey found that while half of the countries reported having national health-climate strategies, less than a quarter achieved high implementation levels. Insufficient financing was identified as the key barrier by 70% of responding countries.

Health’s struggles mirror wider climate adaptation finance gaps. At COP26 in 2021, developed countries pledged to triple overall adaptation finance from 2019 levels to at least $120 billion per year by 2025. Actual flows across all sectors totalled $26 billion in 2023.

Money will determine whether Belém becomes an implemented plan or another symbolic declaration. Without tens of billions in annual funding, it will likely follow previous COP health commitments that failed to translate rhetoric into action.

“The Belém Health Action Plan gives us the blueprint,” said Simon Stiell, executive secretary of the UN Framework Convention on Climate Change. “What we need now is sustained, coordinated and well-financed action to turn its promises into protection for all.”

What’s the plan?

The Belém plan functions as a framework of best practice recommendations for adapting health systems to the climate crisis, containing no legally binding requirements or targets.

Instead, the document outlines recommendations organized around surveillance systems, policy interventions, and infrastructure overhauls that officials say are essential to protecting billions from climate-driven health crises. The one specific requirement: Countries that endorse it will report progress through the Paris Agreement’s Global Stocktake by COP33 in 2028, with no enforcement mechanisms or compliance requirements.

“For decades, WHO has been calling for action to adapt health systems and build resilience to climate change,” said Tedros Adhanom Ghebreyesus, WHO director-general. “The Belém health action plan is how we can do that.”

“Health systems themselves are affected by climate change, compromising their ability to deliver life-saving care when people need it most,” he said. “There can be no healthy people on a sick planet.”

The first focus: building the capacity to see threats coming. The framework calls for climate-informed health monitoring that links meteorological agencies with health institutions, using predictive modelling to trigger early warnings before heat waves, floods, or disease outbreaks overwhelm communities. Surveillance should also track which populations face the greatest risks, data officials say is often missing.

The second area addresses policy interventions to protect communities, including clean energy and sustainable transport, heat protection for workers, mental health support woven into climate response, and targeted measures for Indigenous peoples and persons with disabilities.

”For many countries, adaptation is a question of survival in the short run. If you don’t adapt, it threatens the coverage of health services of patients and professionals who are already facing adverse conditions,” Padhila said. “If we don’t adapt, we are going to increase inequality. In short, if you don’t adapt, we will kill people.”

Water & power

Finance will determine whether the Belém framework’s most ambitious element, climate-resilient infrastructure, can be delivered.

The plan envisions health facilities built to withstand climate shocks, renewable energy powering clinics, telehealth platforms extending care, and strategic stockpiles of temperature-stable medicines and vaccines. It calls for “integrated methodologies linking environmental, meteorological, social, climate and health monitoring data” with real-time surveillance and digital technologies as “structural components.”

The problem: roughly 100,000 health facilities in sub-Saharan Africa lack reliable electricity, affecting nearly a billion people worldwide. Up to 70% of medical equipment in developing countries sits unused due to power failures.

Cold chains for vaccines, digital surveillance systems, early warning platforms, and telehealth services all depend on reliable power that serving populations don’t have. Closing the healthcare electrification gap by 2030 would cost $4.9 billion, about $5 per person affected over six years. That’s less than one year of current global climate-health spending.

“It’s about the billions of people that we have the mandate here to make sure that we can change their lives, promoting health,” said Princess Abze Djigma of Burkina Faso. “It is very important we have the policies… working on the value chains of electricity to make sure that our babies, who are getting born without electricity,” have access to care.

Water and sanitation infrastructure are equally critical, she noted. “If we bring water, we bring sanitation. There is already a disease that we will put away. We can tell our boys and girls to wash their hands, but how could they do it if there is no water at the school?”

The Belém plan’s success will depend not just on building infrastructure, but on countries’ ability to track and report progress. WHO will measure implementation through ATACH, its Alliance for Transformative Action on Climate and Health, which already requires members to complete vulnerability studies, adaptation plans, emissions inventories, and decarbonization roadmaps.

The record so far suggests those demands exceed many countries’ capacity. Four years after ATACH’s launch in 2021, only three countries—France, Japan, and the UK—have completed all four assessments. Across 88 countries with available data, roughly 35-40% completed vulnerability assessments and 30% finished adaptation plans. In Africa, fewer than 10 of 29 ATACH members have completed vulnerability assessments.

The Belém plan now adds reporting requirements on top of those existing gaps: tracking mental health impacts, monitoring workers’ heat exposure, establishing community resilience programmes, and climate-proofing supply chains, all by 2028.

That creates an impossible bind. France, Japan, and the UK have the technical capacity and resources to meet these demands. Many other countries lack not only the expertise for complex reporting systems, but the basic infrastructure, electricity and water, that the plan assumes as a foundation.

“Finance is still the bottleneck for us,” Princess Djigma said.

Fossil fuel phase-out excluded

Notably absent from the plan is any reference to phasing out fossil fuels, the main driver of climate change and the resulting heat, extreme weather and air pollution killing approximately 8m people annually from respiratory and cardiovascular diseases.

The omission came at the explicit instruction of the Brazilian COP30 presidency, according to people familiar with the negotiations.

The exclusion comes as the International Energy Agency warned Wednesday that global oil and gas demand will rise for the next 25 years if countries do not change course. Until this year, all of the Paris-based body’s modelling assumed fossil fuel consumption would peak this decade.

“Climate change is declining — and declining rapidly — in the international energy policy agenda,” said Fatih Birol, the IEA’s executive director. “And this is happening while 2024 was the hottest year in history.”

Birol’s findings align with the Lancet Countdown report published ahead of the summit, which found the 100 largest oil and gas companies have production strategies that put them on track to exceed their share of production consistent with 1.5 °C of heating by 189% in 2040, up from 183% in March 2024.

Private bank lending to fossil fuel activities surged 29% to $611 billion in 2024, exceeding green sector lending by 15%. Some 73 of 87 countries reviewed provided net explicit fossil fuel subsidies in 2023, allocating nearly $1 trillion in direct support. Including indirect subsidies, that figure rises to over $7tn, according to the International Monetary Fund — more than governments spend annually on education and about two-thirds of what they spend on healthcare.

The declining political attention extends to international engagement: Mentions of health and climate change by governments in their annual UN General Assembly statements declined from 62% in 2021 to 30% in 2024, according to the Lancet Countdown.

“Record deaths from climate-driven wildfires in 2023 show that there’s no adaptation without mitigation,” said Nina Renshaw, head of health at the Clean Air Fund. “Ministries of Health and Finance won’t be able to bail hospitals and clinics out of the climate emergency if governments don’t stop the emissions which are already causing unprecedented harm.”

‘More than dialogue’

The Belém plan follows a pattern established at recent climate summits: the COP28 Dubai Health Declaration signed by 143 countries, the Baku Coalition for Climate and Health launched last year, and efforts stretching back to Glasgow in 2021. Like those efforts, Belém is a non-binding, voluntary process taking place outside formal UN negotiations.

Criticisms of the outcomes of Dubai and Baku describe their outcomes as symbolic gestures that generate attention but fail to secure funding, sustained commitment, or implementation. Officials on Thursday repeatedly stressed the need to break the holding pattern.

“This gathering must be more than dialogue,” said Jarbas Barbosa, director of the Pan American Health Organization. “It must galvanise collective action and inspire new policies dedicated to protecting everyone’s health from the worsening effects of climate change.”

“The climatic crisis is fundamentally a health crisis,” Barbosa said. “We are not talking any more about distant or possible threats. Climate change is a present and growing reality.”

Whether the Belém framework can overcome the obstacles that have stymied previous declarations — insufficient financing, limited technical capacity, competing priorities — remains uncertain. But Padilha argued the world has no choice but to try.

“We are faced with a dilemma: we either continue to speak and speak and talk, or we can walk the walk and make the political commitment to do so,” he said. “We cannot accept the erosion of multilateralism in global health. Those who deny multilateralism are surrounding us. We will not listen to them.”

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