INTEGRATING GREEN CARE INITIATIVES INTO TRADITIONAL HEALTH SYSTEM: A LITERATURE REVIEW FOCUSED ON GOVERNANCE DIMENSIONS

INTRODUCTION: The umbrella term Green Care (GC) includes a spectrum of interventions supporting physical, mental, and social health through consciously interacting with nature. Given that GC targets health promotion and disease prevention and rehabilitation, it can potentially improve public healthcare provision, directly responding to modern increases in demand for healthcare in the general population and the specific needs of vulnerable groups. However, public health organizations have not yet fully recognized this potential. Government intervention in health promotion is justified on economic grounds to reduce the impact of market and information failures, particularly negative externalities that undermine people's ability to maximize their welfare. However, actions aimed at expanding care provision can be promoted or undertaken by non-governmental actors acting alone or collaborating with governments. Green Care Initiatives (GCIs) involve professionals from different spheres (e.g., private, public) and various fields (e.g., forestry, healthcare, agriculture) representing diverse environmental, economic, social, and health-related stakes. Therefore, the issue is strictly connected to the partnership composition, decision-making processes, and rules implemented by GC actors. These elements are embedded in the concept of governance and its specific dimensions (i.e., transparency, participation, equity, effectiveness, efficiency, accountability), operationalized in a perspective of joining health to the environment. Therefore, identifying novel governance arrangements could allow GCIs to be recognized within the public healthcare system. Given this, our general aim is to comprehend which governance conditions could enable GCIs to be integrated and institutionalized into the public health system by adopting a novel health and environmental governance perspective. We conducted an international literature review on the adoption of GCIs by healthcare systems by exploring the conditions observed for this to happen and through which specific governance arrangements. METHOD: After defining the problem and the related research questions, we conducted a systematic literature review of international articles following the PRISMA guidelines. Search strings of keywords were combined concerning the themes of "Green Care," "Healthcare," and "Governance" in both Scopus and Web of Science databases. Then, pre-defined criteria were applied to refine the selection of documents relevant to the objectives of our study. Additionally, examples of protocols by healthcare institutions were examined. Finally, relevant findings were synthesized, sorted into tables, and categorized under main themes and dimensions to facilitate qualitative analysis. RESULTS: Sub-dimensions and essential concepts in the overlapping area of GCIs and healthcare governance were identified. Findings from the qualitative analysis indicate that the discourses around governance in GC are more developed in the context of Social Farming, while contrastingly, Forest care initiatives remain little explored. The case study research allowed us to explore more deeply how governance arrangements on the individual project level are embedded in higher-level governance frameworks. CONCLUSIONS: Our results led to an ad hoc governance analytical framework concerning GCIs. This framework could facilitate transparency and evidence-based decision-making to support the integration of GCIs into healthcare practices. Furthermore, these results could help improve monitoring and evaluation processes in GCIs by paving the way for developing an innovative indicators framework based on different health and environmental governance dimensions.