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Introduction: The intersection of health and climate change is often absent or under-represented in sub-national government strategies. This analysis of the literature, using a new methodological framework, highlights priority focus areas for a sub-national government response to health and climate change, using the Western Cape (WC) province of South Africa as a case study.

Methods: A methodological framework was created to conduct a review of priority focus areas relevant for subnational governments. The framework encompassed the establishment of a Project Steering Group consisting of relevant, sub-national stakeholders (e. g. provincial officials, public and environmental health specialists and academics); an analysis of local climatic projections as well as an analysis of global, national and sub-national health risk factors and impacts.

Results: Globally, the discussion of health and climate change adaptation strategies in sub-national, or provincial government is often limited. For the case study presented, multiple health risk factors were identified. WC climatic projections include a warmer and potentially drier future with an increased frequency and intensity of extreme weather events. WC government priority focus areas requiring further research on health risk factors include: population migration and environmental refugees, land use change, violence and human conflict and vulnerable groups. WC government priority focus areas for further research on health impacts include: mental ill-health, non-communicable diseases, injuries, poisonings (e. g. pesticides), food and nutrition insecurity-related diseases, water-and food-borne diseases and reproductive health. These areas are currently under-addressed, or not addressed at all, in the current provincial climate change strategy.

Conclusions: Sub-national government adaptation strategies often display limited discussion on the health and climate change intersect. The methodological framework presented in this case study can be globally utilized by other sub-national governments for decision-making and development of climate change and health adaptation strategies. Additionally, due to the broad range of sectoral issues identified, a primary recommendation from this study is that sub-national governments internationally should consider a " health and climate change in all policies" approach when developing adaptation and mitigation strategies to address climate change.