Abstract
OBJECTIVE: Given the demand for net-zero healthcare, the carbon footprint (CF) of healthcare systems has attracted increasing interest in research in recent years. This systematic review investigates the results and methodological transparency of CF calculations of healthcare systems. The methodological emphasis lies specifically on input-output based calculations. DESIGN: Systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. DATA SOURCES: PubMed, Web of Science, EconBiz, Scopus and Google Scholar were initially searched on 25 November 2019. Search updates in PubMed and Web of Science were considered until December 2023. The search was complemented by reference tracking within all the included studies. ELIGIBILITY CRITERIA: We included original studies that calculated and reported the CF of one or more healthcare systems. Studies were excluded if the specific systems were not named or no information on the calculation method was provided. DATA EXTRACTION AND SYNTHESIS: Within the initial search, two independent reviewers searched, screened and extracted information from the included studies. A checklist was developed to extract information on results and methodology and assess the included studies' transparency. RESULTS: 15 studies were included. The mean ratio of healthcare system emissions to total national emissions was 4.9% (minimum 1.5%; maximum 9.8%), and CFs were growing in most countries. Hospital care led to the largest relative share of the total CF. At least 71% of the methodological items were reported by each study. CONCLUSIONS: The results of this review show that healthcare systems contribute substantially to national carbon emissions, and hospitals are one of the main contributors in this regard. They also show that mitigation measures can help reduce emissions over time. The checklist developed here can serve as a reference point to help make methodological decisions in future research reports as well as report homogeneous results.