Dialogic air pollution and health systems integrated framework (APHSiF): A holistic underpinnings

Background: The impact of air pollution is a barrier to achieving the Sustainable Development Goals. While it is identified within SDGs 3, 7, 11 and 12, the existing policy and approaches rarely integrate air pollution as an issue with a health systems lens. Air pollution is a complex and multisectoral problem influenced by various elements. Absence of dialogue across these interacting elements from governance structures upto the individual further adds to its intricacy. We aimed to undertake a systematic review of existing frameworks integrating air pollution and health systems, and to develop a conceptual framework to address the identified gaps.
Methodology: We used multimethod approach which was iterative and reflexive in nature. A systematic review was conducted in PubMed, EBSCOhost, Google Scholar, Embase, Web of Science and Scopus published between 2000 and 2025 using key words “Health Systems,” “Air Pollution,” “Integrated,” “Conceptualisation,” “Framework” using Boolean operator limited to English language. The second process involved developing an element of the framework and later the Health Systems expert’s consultation to refine and validate the framework with the researchers’ knowledge and experience.
Results: Total of 160 records were identified, of which two studies met inclusion criterion after screening of title, abstract and full text. As we could not find any standard framework in the literature, based on health systems research, we drafted an initial framework by modifying the basic elements of air pollution, health systems research,  understanding of complex adaptive systems and through the review of the field. The first version was discussed and suggestions were incorporated to have a final round of discussion with Health Systems researchers to generate the final version of the conceptual design. We present an air pollution and health systemsintegrated framework consisting of two interconnected pathways: the problem pathway and a response pathway. The problem pathway conceptualises how environmental drivers including climate change and anthropogenic activities, contribute to air pollution hazards, which in turn affect health outcomes through mechanisms of vulnerability (a function of exposure, sensitivity, and adaptive capacity). The response pathway describes how the health systems and the three tier governance structures at macro, meso and micro level respond to the risk. In between the two pathway, the fulcrum factors (equity, systems and programmatic levers)  serves as a critical pivot point. When these factors are adequately responsive and prepared, they strengthen the overall systems ability to respond as whole. The framework positions itself into public health discipline frame and therefore it leads to the adoption of determinants factors which influence the systems response to environmental drivers (Socio-Political-Economic-Cultural and Topographic). It incorporates two pathways to reflect a complete cycle of risk, governance, and health outcomes. It also lends itself to studying holistically on how various interrelated factors work together to influence exposure mitigation strategies.
Conclusion: To the best of our knowledge, this is the first framework which integrate air pollution risk pathways and health systems response mechanisms. It provides a systems based perspective for analysing air pollution as a public health emergency. By linking the environmental drivers, vulnerability pathway with a health risk, social equity dimension and systems integrated responses, it offers a structured approach for research, policy development and health systems adaptation to air pollution and related risks.
Key words: health systems, air pollution, health risk, conceptual framework, multi method.