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Exacerbating Health Risks in India due to Climate Change: Rethinking Approach to Health Service Provision

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While climate change is expected to exacerbate human health risks, it also provides an excellent opportunity for defining and implementing preventive actions. Developing nations like India, with low infrastructure facilities, limited resources, varied development priorities and, often with large population, are particularly vulnerable to health impacts-more so under the climate change regime. The greatest challenge facing the current Indian health service provisioning system is that it has to cater to the health service needs of its large population within a short time and with sustainable impact. Limited health 'cure infrastructure' (low per capita availability of doctor, hospital beds, etc.), lack of qualified health practitioners, absence of a strong monitoring system in disease surveillance and rising cost of 'cure infrastructure' are some of the major drawbacks of the existing system in India. There is therefore, a need for mainstreaming more preventive measures which will enhance human health resilience and make the population less exposed and more resilient to the predicted impacts of climate change. To provide preventive care to the Indian population, a paradigm shift in strategy is required. The new regime needs to emphasize on an integration of 'traditional preventive health care systems' with modern cure targeted pharmaceuticals and non-health sector interventions. Such a system is expected to reduce the long term demand for cure infrastructure and will provide a more holistic inclusive solution to the Indian problems.
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Exacerbating Health Risks in India:
Rethinking Approach to Health Service
Provision
Joyashree Roy1, Duke Ghosh2*, Kuheli Mukhopadhyay3, Anupa Ghosh4
ABSTRACT
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Climate change is expected to exacerbate human health risks but provide opportunity for preventive
actions. Developing nations like India, with low infrastructure facilities, limited resources, diverse
development priorities and often with large population, are particularly vulnerable to health impacts -
more so under the climate change regime. The greatest challenge facing the current Indian health service
provisioning system is that it has to cater to the health service needs of its large population within a short
time and with sustainable impact. Limited health ‘cure infrastructure’ (low per capita availability of
doctor, hospital beds etc), lack of qualified heath practitioners, absence of a strong monitoring system in
disease surveillance and rising cost of ‘cure infrastructure’ are some of the major drawbacks of the
existing system in India. There is need is for more preventive measures which enhance human health
resilience and make them more adaptive to predicted long term changes. To provide preventive care to the
Indian population, a paradigm shift is required. The new regime needs to emphasize on an integration of
traditional preventive health care systems with modern pharmaceuticals and non health sector
interventions. Such a holistic system will reduce need for cure and will have universal acceptance due to
inclusiveness among all socio-economic classes across nations thereby ensuring the future success and
robustness of the system.
Keywords: climate change, cure infrastructure, sustainable, preventive health care, resilience.
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1Professor of Economics & Coordinator, Global Change Programme, Jadavpur University, Kolkata
2Partner & Researcher, Global Change Research, Kolkata, email: duke.ghosh@globalchangeresearch.in
2Partner & Researcher, Global Change Research, Kolkata, email: duke.ghosh@globalchangeresearch.in
3Research Project Fellow UPEII (UGC), Global Change Programme, Jadavpur University and Doctoral
Fellow, Department of Economics at West Bengal State University, Barasat
4Assistant Professor, Department of Economics, The Bhawanipur Education Society College, Kolkata
*Corresponding Author
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INTRODUCTION
Human health determines individual and societal wellbeing. Climate change induced health impacts are
expected to put stress on human wellbeing and equity through intra-generational and inter-generational
health outcomes. Understanding the climate change - human health interaction is imperative for
sustainable development. There is insufficient evidence, assessment, research based knowledge and
communication on climate change induced health risks, impacts and intervention need assessments. Our
line of argument is that to ensure sustainable development in India there is a major need for development
of a National Preventive Health Care Mission (NPHCM5) under the umbrella of NAPCC (National Action
Plan on Climate Change). This mission mode can expedite the sustainable development process through
targeted preventive actions that can reduce health impact and accelerated demand on cure infrastructure.
The goal of this article is to develop the concept and arguments towards development of NPHCM through
multi-disciplinary, multi-sectoral and multiple health systems approach. A holistic social welfare based
system that combines the best approaches in both traditional preventive and modern cure health systems
and are governed by socio-economic realities is being suggested. Past research shows that the most
important threat to India’s sustainable development is poor performance in the health care sector. Climate
change will make it additionally worse due to the lack of preventive approach in the health sector (Roy &
Netinder, 2010).
This article is based on information gathered from secondary sources and through primary expert
interviews. We propose that climate change induced disease category-wise multidisciplinary action
research groups (ARGs) can lead, plan and execute a holistic and preventive health care system that
would address climate change induced health risks. With a goal towards sustainable development, the
2009 NAPCC and the Indian Network for Climate Change Assessment (INCCA) of the Government of
India are providing a platform for multiple stakeholders to address climate change related problems in the
country. However, there is no separate action plan to target health impact reduction in the NAPCC. We
propose that given the dearth of strategy and the immediacy of the problem, addressing the health impact
issue in the mission mode would have the advantage of expediting the action through planned steps and
targets while simultaneously generating ample scope for large scale finance mobilization that can
mobilise private action as well as global adaptation fund to enhance resilience.
Climate data shows a clear rising trend in global mean surface temperature. Recent projections under
different representative concentration pathways (RCP) scenarios predict that this global warming will
continue and further accelerate in the future (IPCC, 2013). According to IPCC (Intergovernmental Panel
on Climate Change) reports, if the global society continues to emit green house gases at current rates, the
average global temperature could rise by 2.6 °C to 4.8°C by 2100. Research indicates that one of the
major fallouts of temperature trend can be heat stress (Samet, 2010), (Kjellstrom, Lemke, & Hyat, 2011),
(Mathee, Oba, & Rose, 2010), (Roy, 2010), (Roy, Chakrabarty, Mukhopadhyay, & Kanjilal, 2011). a
major health risk. Health risks are also posed by exposures to other extreme events like floods, droughts,
etc., whose incidences and frequencies are likely to increase due to climate change. These events result in
death, disease, mental trauma and malnutrition through water scarcity, loss of food security, increased
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$"The idea was presented for consideration in a report submitted to SIDA (Roy & Netinder, 2010). The report was
prepared based on an extensive literature review and detailed interview of the national and international agencies
and stakeholders."
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transmission of infectious diseases as a result of the influence of climate change on disease vectors,
societal and economic disruptions due to migration, etc. (see Table 1 and Figure 1).
Table 1 Potential Health Impacts of Climate Change
Threats
Consequences
Increased frequency and intensity of heat waves
Increased mortality from heat waves, especially among elderly
Altered distribution of aeroallergens6
Increased frequency and severity of allergic diseases and
symptoms
Altered distribution of infectious disease vectors
Increased frequency and spread of infectious diseases
Increased air pollution
Increased morbidity and premature mortality
Changing agricultural yields
More undernourished people in low-income countries
Social and economic disruptions due to extreme events, wars,
etc.
Water borne diseases, malnutrition
Source: (Samet, 2010)
Given the multidimensionality of the problem, there is a growing political commitment to integrate health
considerations into efforts to mitigate and adapt to climate change at different national and regional
levels. But these efforts are still limited (Rumsey, et al., 2014), (WHO SEARO, 2007). To strengthen our
arguments for a more concerted and expansive effort to cope with the health impacts of climate change in
a demographically expanding country like India, in section 2, we present select examples of heat stress
related direct human workability impact together with temperature and water quality impact in urban
India to establish why preventive measures/policies/adaptive strategies can enhance resilience to climate
change related health impact. Section 3 presents expert interview based assessment of barriers and gaps in
the current cure-focused healthcare regime. The intent is to propose in section 4 an institutional
arrangement that might efficiently integrate strategies to combat the climate risks to human health with
the extant health care system in the country.
The conceptual framework that has been used to formulate the problem and design a holistic system to
manage health impact risks better is guided by an integrated approach (figure 1) that connects climate
variability to human wellbeing loss. We consider preventive care as process intervention and cure as end
of pipe intervention. Latter is following the philosophy of pollute now clean up later approach which is
relatively costly as it can have many external costs also.
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&"An aeroallergen is any air borne substance which triggers an allergic reaction. Aeroallergens include pollen grains,
spores etc. Aeroallergens pose a direct threat to many people who already suffer from respiratory illness and people
who develop problems after exposure. "
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Figure 1 Health Impacts of Climate Change
CLIMATE CHANGE AND THREATS TO HUMAN HEALTH: INDIAN CONTEXT
India, a major demographic and economic force among South Asian nations, covers almost 2.3% of the
world’s land area while being home to nearly 18% of the world population (NATCOM, 2012). Empirical
evidences show that the biggest threat to sustainable development in India comes from relatively worse
performance and slow progress in the health sector (Roy, Chatterjee, & Basak, 2008). Analysis of the
sustainability indicators in India conducted during 2008-09 show that 28 out of the 35 states and union
territories7 in the country need to prioritize environmental and pollution related health issues in order to
be on a sustainable development pathway (see figure 2)8. Many of these states show that most of these
health issues involve vector and water borne diseases and air pollution related health impacts. Under the
projected climate scenarios, the vulnerability to these health risks is likely to increase. Thus addressing
the health outcome is a major entry point for integration with climate response strategies.
Since the Indian independence in 1947, there has been considerable improvement in the life expectancy of
her populace. Life expectancy has more than doubled from 32 years in 1947 to 66 in 2004 (NATCOM,
2012). Mortality and fertility rates have been simultaneously reduced (see table 4). While these
information underscores the benefits accruing from improvements in cure focused medical system, it does
not guarantee that vulnerability to climate induced health risks has been minimized. Table 2 gives a brief
account of the health concerns in India due to climate variability. The magnitude of the problem can be
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("In 2008-09, India had 28 states and 7 union territories. However, with effect from June, 2014, the country has been
reorganized and the state of Andhra Pradesh has been divided into two sates Andhra Pradesh and Telangana.
Therefore, at present the country has 30 states and 7 union territories. """"
)"Source: (Roy, et al, 2008)"
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gauged from the fact that India accounts for about 8% of the malarial cases that are reported globally per
annum (GOI, 2011). Within the South-east Asian region, 70% of all malarial cases reported annually are
accounted for by India. Dengue, identified by WHO as one of the 17 most neglected tropical diseases, is
endemic in 31 states and union territories in the country. Of the 350 million global population exposed to
the risk of developing kala-azar, about 129 million reside in India. According to the World Health
Organization, worldwide, diarrhoea is the second major cause of death among children under five years of
age (GOI, 2011). In India 10% infants and 14% children in the age group 0-4 years die annually due to
diarrhoea (UNICEF, 2009). Therefore, under the current conditions of climate change, the health risks in
India are likely to accelerate if immediate actions are not taken to reduce vulnerability.
Vulnerability to climate change impacts is a function of exposure, sensitivity and adaptive capacity
(IPCC, 2001). Preventive measure reduces exposure and hence vulnerability. Depending on the
geographic, demographic, socio-cultural, economic characteristics of a place, the vulnerability to climate
change varies. In India the vulnerability is high given the diverse geographic features of its large
landscape, high population growth rate and an economic system that is predominantly developing9 in
nature. A largely rural society, about 70% of the rural population in India is directly dependent on
climate sensitive sectors like agriculture, forestry, and on natural resources such as water, biodiversity,
mangroves, coastal zones and grasslands for the continuation of their livelihood (Majra & Gur, 2009).
Thus the vulnerability to the adverse impacts of climate change appears high. Natural adversities like heat
waves, droughts, floods along with incidences of malaria, malnutrition, diarrhoea, heat related mortality
and morbidity, asthma, heart diseases, are some important human health issues that are likely to rise
owing to climate change (Majra & Gur, 2009). Our goal is to show in following two examples how
exposure can be reduced by preventive measures.
Table 2 Climate Induced Health Risks in India
Health Concerns
Vulnerabilities due to Climate Change in India
Temperature related morbidity
Heat and cold related illness
Cardio vascular illness
Vector-borne diseases
Changed pattern of disease; malaria, dengue, filaria, kala-
azar, Japanese encephalitis and dengue caused by bacteria,
virus and other pathogens
Extreme weather events
Diarrhoea, cholera and poisoning caused by biological and
chemical contaminants in water
Damaged public health infrastructure owing to cyclones,
floods, injuries, illness etc
Social and mental health stress owing to disaster and
displacement
Effects due to insecurity in food production
Mal nutrition and hunger especially among children
Source: (NATCOM, 2004)
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9 Characteristic features of a developing economy includes low income levels, distributional inequality, poor health,
inadequate education, low productivity, high population growth and dependency burden, substantial dependence on
primary sectors, imperfect markets and limited information (Todaro & Smith, 2007).
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Figure 2 Major issues of concern in India
Source: (Roy, Chatterjee, & Basak, 2008)
HEAT RELATED HEALTH IMPACTS
Heat related illness is often recognized as a major health issue (Kjellstrom, Lemke, & Hyat, 2011) (Dapi,
Rocklöv, Nguefack-Tsague, Tetanye, & Kjellstrom, 2010). Given the rising temperature trends and
increasing frequency of heat events, health issues like heat exhaustion, heat cramps, heat stroke and death,
etc. are on the rise (Luber & McGeehin, 2008), (McMichael, Woodruff, & Hales, 2006). The impacts of
heat stress differ depending on factors like adaptive capacity, occupational pattern of the people and
hence exposure, age structure, etc. (table 3).
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Table 3 Population Most Vulnerable to Heat Stress - Global Indicators
Vulnerable Population
Risk Factor
Elderly (above 50years)
Poor thermoregulatory mechanism
Impaired cognitive function
Children
Greater surface area to body mass ratio leading to
greater heat gain than adults
Produce more metabolic heat per unit of mass when
engaged in physical activity
Less physiologic capacity to sweat
More time to acclimatize than adults
Participants in athletic events
Dehydration
Outdoor workers (street vendors, rickshaw pullers, poor
and subsistence farmers and pastoralists)
Inadequate cooling off or rest periods
Insufficient water consumption
Dehydration
Inappropriate clothing
Excessive sun exposure
Medically compromised and socially isolated
Mental illness which accompanies social isolation
Inability to avoid heat exposure owing to lack of
social contact who can intervene on their behalf
Source: California Department of Public Health (http://www.ehib.org/page.jsp?page_key=173)
(Sahni, 2013), (MMWR Morbidity and Mortality Weekly Report, 2010)
Between 1980 and 1998, as many as 18 events of heat waves were reported in India. The one in 1988
affected about 10 states and resulted in 1300 deaths. Between 1998 and 2000, several heat waves caused
an estimated 2120 deaths in Odisha and 198 deaths in West Bengal. In 2003 the heat wave in Andhra
Pradesh caused more than 3000 deaths while West Bengal recorded 52 deaths (IPCC, 2007). Between
2001 and 2008, the number of accidental deaths due to heat stroke gradually increased in different states
in India, with specific concentration in some particular states like Andhra Pradesh, Orissa, Uttar Pradesh,
West Bengal, Bihar and Punjab. The death toll due to heat stress continues to rise (Table A1 in appendix),
so much so that in 2010 the percentage share of deaths from heat stroke to total deaths in India was 5.1%
(GOI, 2010). It has been observed that regions with average annual temperature above 25˚C are
particularly susceptible to heat waves. Hence states like Andhra Pradesh, Orissa, West Bengal, Uttar
Pradesh, Bihar, Jharkhand and Gujarat are highly vulnerable to heat stress.
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Figure 3 Annual Temperature Map of India
Source: Based on data published by India Meteorological Department, Government of India10
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A case study of Kolkata (Roy, 2010)on the direct impact of heat stress on workability shows that
anticipated temperature trend will exacerbate heat stress. During the last forty years in Kolkata, days in
April have become warmer by 0.01˚C-0.7˚C per decade whereas days in January have become cooler by
0.04˚C-0.5˚C per decade (Roy, 2010). On the other hand January nights have become warmer by 0.02˚C-
0.9˚C per decade and April nights have become warmer by 0.02˚C-0.6˚C per decade. These changes are
going to be more in the warming direction in the coming decades. So exposure to heat and related health
disorders are assuming importance. Human body functions the best within a narrow range of “core”
internal temperature that varies from 36˚C to 38˚C. Increase in the core internal temperature leads to heat
disorders in human beings. An individual can work safely in an environment for extended periods of time
only when the balance between the heat gain due to metabolism and the heat lost to the environment is
maintained. Heat related disorders are a group of illnesses caused by prolonged exposure to hot
temperatures, restricted fluid intake, or failure of the body's ability to regulate its temperature. Heat stress
has direct implications for human workability through reduced work performance as tired, fatigued
workers perform with reduced accuracy, efficiency (Dash & Kjellstrom, 2011), (Coris, Ramirez, & Van
Durme, 2004). We have used WBGT index (ACGIH, 1995) and measured 100% workability window for
Kolkata using 2009 data11 . The estimates show that for outdoor work categories, e.g. construction
workers, traffic police, rickshaw pullers, joggers, walkers, gardeners and cyclists, even in 2009 climate
condition and without any adaptation strategy, is failing to provide 100% workdays for more than 9 days
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in 365 days and even 25% work days are possible for only 44 days without creating any heat stress related
health impact (table A2).
The impacts of heat stress vary depending on adaptive capacity, occupational pattern of the people (Roy,
2010). The effects of climate change on disease and mortality is expected to have a greater impact on
impoverished people who cannot afford minimum living quality (Frakson, 2009). Urban poor are
particularly vulnerable to “urban heat island” effect. Excessive heat exposure affects people with certain
pre-existing medical conditions like cardio-vascular disease, respiratory illness and obesity.
The working population who are exposed to heat for most of the day time are highly susceptible to the
heat related morbidity and mortality. Poor and subsistence farmers and pastoralists are not only
vulnerable to the heat stress due to their outdoor exposure but also vulnerable to the impact of heat on
crop yield and livestock. During the 2003 heat wave in the southern Indian state of Andhra Pradesh, when
temperatures rose to almost 49˚C, over 1,200 people died. Majority of the dead were poor daily wage
labourers, rickshaw pullers and construction workers.12
Other than the exposure of the working population to heat stress, the elderly population is at higher risk
due to reduced ability to acclimatize to changing temperatures and higher likelihood of pre-existing
chronic health conditions the thermoregulatory mechanisms in older adults often do not function
optimally, even when the individual is relatively healthy (Nag & Nag, 2009), (Brahmapurkar, et al.,
2012), (California Department of Public Health and the Public Health Institute, 2007). However, the
effect of heat stress on the aged is more a concern in the developed world than in India. Statistics indicate
that the age distribution of deaths due to heat induced heatstroke is more or less uniform in India (Bal,
Pant, Maurya, & Periasamy, 2012). In fact, the most susceptible group in the country are daily wage
labourers. Thus socio-economic conditions, rather than demographic factors, influence the vulnerability to
heat stress in India.
Under such circumstances, the conventional health cure systems cannot be a solution. A preventive health
care system would be more appropriate as that can enhance adaptive capacity by reducing exposure
Various simulation results show that exposure levels can be reduced by changing clothing type, providing
shades, indoor work space and air conditioning, and changing work timings are possible preventive
measures to address heat stress related occupational hazards. Costs vary with preventive measures and
actions need not always fall under the purview of the health care sector but can lie in formulating
innovative labour rules, work hours, dress code, work space design etc.
A second case study using the Kolkata Municipal Corporation (KMC) data base was also conducted to
study the impact of climatic variability on piped water supply to various category of consumers (Roy,
2010). KMC undertakes regular water sample collection from stand-posts all across the KMC area, outlet
points of the booster pumping stations and end-use points in public schools, hospitals and government
offices. These are tested for quality in their own laboratory where the physical parameters such as
turbidity, taste and odour, colour, chemical parameter such as dissolved chlorine and bacteriological tests
are executed. An analysis of the data (table A3 and figure 4) shows that the percentage of confluent
samples (i.e. samples in which coliforms of faecal/non-faecal origin are found) is found to increase
significantly in summer and monsoon seasons. Discussion with the KMC scientists reveal that in summer
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with rise in temperature, the amount of dissolved chlorine in piped water reduces. This increases the
likelihood of bacterial growth in piped water.
The quality aspect of the piped water supplied by the KMC has long-term sustainability implications
under the climate change scenario. Under the climate change scenario a significant prediction is that
summers will be prolonged. This may lead to a significant deterioration of water quality for a prolonged
period, thereby increasing the consumers’ vulnerability to health risks. Preventive health care by
maintaining water quality with additional efforts from KMC can save both public and private cost of
curing water borne diseases like diarrhoea, cholera, hepatitis and typhoid. These examples show that
preventive health care measures can happen across sectors to deliver benefits in the health sector
outcome.
Figure 4 Seasonal Variations in Quality of Piped Water in KMC Area
INTEGRATING “CLIMATE CHANGE” AND “HEALTH ISSUES”: GAP IDENTIFICATION
It is important to understand gaps in the existing system to suggest any institutional reform. We present
current cure system focused institutional adequacy and an assessment of climate change induced health
impact awareness among health sector decision makers.
BRIEF OVERVIEW OF THE INDIAN HEALTH SYSTEM AND POLICY
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The Indian healthcare system has witnessed a sea change since independence in 1947. The transition of
the Indian health system has basically been a combination of demographic transition (shift from high
mortality and fertility to low mortality and fertility), epidemiological transition (from mal nutrition to
communicable diseases of childhood to chronic diseases of adulthood), social transition (from low to high
knowledge and expectations about the health services) and technological transition (both diagnostic and
therapeutic) that have contributed to shift in policies and programmes with cure focus in the health sector
(Peters, Rao, & Fryatt, 2003). The National Health Policy (NHP) formulated in 1983 and then revised in
2002 puts forward the basic goal to improve health, and further deliberates on the methods and policies to
achieve the same. The long term goal of the NHP has been to achieve, by 2045, a stable population that is
consistent with sustainable economic growth, social development and environmental protection. After
more than half a century of independence, the performance of the Indian health system has been
satisfactory with respect to these goals (Peters, Yazbeck, & Sharma, 2002), yet a lot more needs to be
achieved.
Table 4 Health Indicators of India Since Independence
Health Indicators
1951
Current
Source
Crude Death Rate
(per 1000 population)
22.8
7.9 (2012)
(World Health Statistics 2014)
Birth Rate
41.7
22.1 (2010)
(SRS Bulletin, December 2011)
Infant Mortality Rate
(both sexes)
146 per 1000
live births
44 (2012)
(World Health Statistics 2014)
Life Expectancy at Birth
(both sexes)
32.1
66 (2012)
(World Health Statistics 2014)
Total Fertility Rate
(per woman)
6.0
2.5 (2012)
(World Health Statistics 2014)
The greatest challenge facing the current Indian health service system is that it has to cater to the health
service needs of a large population within a short time with sustainable impact. With 21.92% of the
population, living below the poverty line, it is undoubtedly a tough challenge (GOI, 2013). Since
independence, the primary goal of the policy makers has been to ensure regional and demographic equity
in the distribution of health services in the country. So far, the Indian health policy has accorded
importance to visible issues like maternal mortality, maternal health, infant mortality and child health,
malnutrition and under-nutrition, and reducing the incidence of certain communicable diseases like
malaria, dengue and cholera that can lead to the outbreak of epidemics. These have been the main
concerns of the policy makers particularly in the poor and less developed regions of the country (Peters,
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Yazbeck, & Sharma, 2002). However, the significance of the integration of climate change impact control
measures and health strategies an important aspect of sustainability, has been lost (Patil,
Somasundaram, & Goyal, 2002). After over fifty years of independence, 40% of the deaths in rural India
are due to infectious diseases and 80% of the sickness is due to water borne diseases (Patil,
Somasundaram, & Goyal, 2002). While the immediate problems loom large, preparing for preventive care
or planning for the emerging risks due to climate change have been rather peripheral to the health policy
of India. To combat the emerging health risks arising due to climate change there seems to be an
immediate necessity for a redefinition of priorities and for renewed focus.
A robust cure oriented health system calls for a strong focus on health infrastructure and healthcare
personnel. The ratio of doctors to Indian population stands at 1:1800. According to the Medical Council
of India, the total number of doctors registered in the country up to 31st March 2012 was 8, 52,195
(Medical Council of India Annual Report (Ammended), 2011-2012). The situation is considerably better
in urban India where the doctor-to-population ratio is almost six times than that in the rural areas
(Gangolli, Duggal, & Shukla, 2005). Health Statistics shows that India had only 0.7 physicians per 1000
population (OECD average being 3.2) and less than one nurse in 2010 (OECD average being 8.7) per
1000 population in 2011. While the global ratio of hospital beds per 10,000 people is 30, it was only 9 per
10,000 people in India during the period 2005 to 2012 (World Health Statistics 2013). This is despite the
fact that during 2004-13, there has been a significant increase in the number of beds in government
hospitals (excluding AYUSH hospitals13 and ESI14 hospitals). Thus it is evident that the increase in
hospital beds has not been commensurate with the population growth rate. Further, an average nursing
home and private health facility in India has only 22 beds which is significantly low compared to other
nations (Jain & Sandeep, 2009). WHO had estimated that India will need an additional 80,000 hospital
beds each year for the next five years to meet the demands of its population (Bhat, 2006). Again the
availability of health facilities in India has a distinct urban bias (Gangolli, Duggal, & Shukla, 2005).
Since more than 70% of the population live in rural India (Census of India, 2011), this excludes a large
chunk of the populace from the benefits of modern medicine in the country. Thus there appears to be
immense scope for investment in the healthcare system in the country. It is also necessary to take a relook
at the type of investments made in healthcare in the country so as to ascertain whether climate resilient
investment has been an objective of the health policies so far.
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13 Hospitals specializing in alternative medicines -Ayurveda, Yoga and Naturopathy, Unani, Siddha and
Homoeopathy (AYUSH)
14 ESI Employees’ State Insurance Corporation’s Hospitals"
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Figure 5 Physicians per 10000 People (2003-2012) in Different Countries
Source: (UNDP, 2014)
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Figure 6 Distribution of Allopath Doctors in India (1961-1981)
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Source: Compiled from statistics released by National Commission for Women, Govt. of India (1961,
1971, 1981)15 "
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Figure 7 Number of Beds in the Government Hospitals in India
(Including Community Health Centres)
Source: Compiled from statistics published by the Ministry of Health and Family Welfare, Government of
India16"
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Table 5 Hospital Beds (Per 10,000 Population) during 2005-2012
Country
Hospital beds per
10000 people
Global
30
Japan
137
Australia
39
Norway
33
UK
30
USA
30
Sri Lanka
36
Brazil
23
China
39
Malaysia
18
Pakistan
6
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India
9
Bangladesh
6
Niger
Ethiopia
63
Nepal
50
Senegal
Source: (World Health Statistics 2013)
HEALTH INFRASTRUCTURE IN INDIA
Over the years the public health investment in India has traditionally been low (GOI, 2002). Health
expenditures computed on the basis of a few selected list of National Health Account indicators for the
years 2000 and 2011)(table 6) show that during the last decade there has not been any satisfactory
improvement in expenditure on health in the country. The contribution of public funds to total health
expenditure has been consistently lower than private expenditure. In most developed economies, the
general norm is that health services are largely funded by the government. In India however only about
30% of the total expenditure health is contributed to by the government, the rest is financed privately. An
idea about the public healthcare system can be had from the country’s HDI ranking (UNDP, 2014). The
HDI is calculated taking into consideration factors like health, education and per capita income.
According to the UNDP, out of 187 member countries, India’s HDI ranking is 135. A comparative
analysis (table 5) of some major health statistic across countries, both developed and developing, show
that there is considerable scope for government action in the healthcare system in India. This scenario has
encouraging possibilities for the future of healthcare as there is still immense possibility for the
government to intervene with policies that can henceforth mainstream climate responsive health
infrastructure into the health care framework of the country.
Table 6 Measured Levels of Expenditure on Health in India
Selected National Health Accounts Indicator
2000
2011
Total expenditure on health as % of GDP
4.3
3.9
General Government expenditure on health as a % of
total expenditure on health
26.0
30.5
Private expenditure on health as a % of total
expenditure on health
74.0
69.5
General government expenditure on health as a % of
total government expenditure!
7.4
8.2
External resources for health as a % of total
expenditure on health
0.5
1.1
Source: (World Health Statistics 2014)
!&"
"
Table 7 Health Indicators (2011) and Health Spending (2010) in Selected Countries
Country
HDI
Rank
2013
Life
Expectancy
at Birth
(years)
IMR 17
Total
Health
Spending
as a % of
GDP
Govt.
spending
on health
as a % of
Total
spending
on health
Private
spending on
health as a %
of Total
spending on
health
Govt
spending
on health
as a % of
Total Govt
spending
External
resources for
health as a %
of Total
spending on
health
Norway
1
81
3
9.3
85.5
14.5
17.7
Sweden
12
82
2
9.6
81.0
19.0
14.8
Japan
17
83
2
9.2
80.3
19.7
18.2
USA
5
79
6
17.6
48.2
51.8
19.9
UK
14
80
4
9.6
83.2
16.8
15.9
Malaysia
62
74
6
4.4
55.5
44.5
9.2
0
Brazil
79
74
14
9.0
47.0
53.0
10.7
0.3
Sri Lanka
73
75
11
3.5
45.6
54.4
6.9
2.2
India
135
65
47
3.7
28.2
71.8
6.8
1.3
Pakistan
146
67
59
1.0
76.6
23.4
3.4
10.2
Niger
187
56
66
4.8
49.2
50.8
11.1
32.7
Source: (World Health Statistics 2013), (UNDP, 2014)
A further analysis of the recent health policies in the country reveal that improved rural healthcare and
access to affordable public health systems have been accorded necessary priority in the country. The
National Rural Health Mission: 2005-2012 (NRHM) is a major initiative by the Indian government that
seeks to provide effective healthcare to the rural population throughout the country with special focus on
18 states that have weak public health indicators and/or weak infrastructure. The NRHM programme is
also aimed at improving public health infrastructure and access at the community level through increased
decentralization of health functions (table 8). Furthermore, the Government of India launched the
Rashtriya Swasthya BimaYojana (RSBY) program in April 2008. The initiative is aimed at providing
low-cost health insurance coverage to BPL (below poverty line) patients and to those engaged in the
unorganized sectors, who might not have previously been insured or been able to afford medical
treatment. Under the RSBY scheme, beneficiaries are entitled to health insurance coverage of up to Rs.
30,000 per year. Patients covered under the scheme can avail cashless transactions to gain access to
treatment in hospitals and healthcare centres registered under the RSBY scheme. The scheme entails a
public-private partnership between the government and private insurance companies. Although the
scheme is fairly recent and still operating at a small scale, RSBY has attained some success in states such
as Maharashtra, Uttar Pradesh and Bihar.
Recent trends in health policies in India emphasize the need to incorporate climate oriented health
systems in the country. Ensuring accessibility to health systems and improving rural health infrastructure
ensures the equity goals of the country’s national health policy. However, beside distributional and
regional equity there is both necessity and possibility for incorporating climate driven systems that while
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
"
"
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ensuring the immediate equity and accessibility issues; also guarantee the long term/ inter-generational
equity and sustainability criteria. In this regard there is already in place a traditional medical system that
through restructuring and proper administration might address the sustainability goals of the Indian health
system while being both affordable and accessible to all.
Table 8 Goals and Strategies of NHRM (2005 -2012)
Goals
Universal access to public health services such as Women’s health, child
health, water, sanitation & hygiene, immunization, and Nutrition
Prevention and control of communicable and non-communicable diseases,
including locally endemic diseases
Increased access to integrated comprehensive primary healthcare
Population stabilization, gender and demographic balance and promotion of
health lifestyles
Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio
(MMR)
Core Strategies
Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own,
control and manage public health services
Promote access to improved healthcare at household level through the
female health activist (ASHAs)
Health plan for each village through Village Health Committee of the
Panchayat
Strengthening sub-centre through an untied fund to enable local planning and
action and more Multi Purpose Workers (MPWs)
Strengthening existing PHCs and CHCs and provision of 30-50 bedded
CHC per lakh population for improved curative care to a normative standard
(Indian Public Health Standards defining personnel, equipment and
management standards)
Preparation and implementation of inter-sectoral District Health Plan
prepared by the District Health Mission, including drinking water, sanitation
hygiene and nutrition.
Integrating vertical Health and Family Welfare programmes at National,
State, Block and District levels
Technical support to National, State and District Health Missions for Public
Health Management.
Strengthening capacities for data collection, assessment and review for
evidence based planning, monitoring and supervision
Formulation of transparent policies for deployment and career development
of Human Resources for Health
Developing capacities for preventive healthcare at all levels for promoting
healthy life styles, reduction in consumption of tobacco, alcohol etc
Promoting non-profit sector particularly in underserved areas.
"""""""""""Source: (Ministry of Health and Family Welfare, 2005-2012)
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GAPS AND CHALLENGES
Based on the expert interviews18 and supplemented by secondary information the gaps that impede the
capacity of the Indian health sector to combat the emerging climate induced health risks have been
identified (Table 9, 10). The gaps mainly emerge due to the absence of proper integration of climate
change related stresses in designing approaches and policies for the health sector in India. Table 9
represents a summary of the barriers while table 10 summarizes the gaps.
Table 9 Barriers in Mainstreaming Climate Change in the Indian Health Sector
Area
Observations concerning Climate Change and Health
Integrating climate
change and health at the
policy level
Issue of climate change is yet to “seep down” to people who matter the politicians,
policy makers, etc.; impacts of climate change are often considered as “distant”.
Awareness about the “phenomenon” called climate change may be existing at the
highest level (the government) but there may be absence of “realization” among
decision makers about exact impacts at the local level impeding area specific
intervention(s).
Although it is important to start planning to tackle the emerging risks from climate
change in the health sector, recognition of this requirement, especially, at the policy and
the budget level is still awaited.
There may be a view at the policy making level that there is not enough evidence (of
how climate change will affect health) to plan for interventions.
So far, there is almost no programmatic approach at the policy level to devise strategies
for the health sector with climate change as a perspective.
The issue of climate change is often recognized as an “additional burden” and “an issue
with uncertainty in scientific knowledge and understanding.” For the present health
system of India, already plagued with a number of problems maternal mortality,
infant mortality, malnutrition, etc., it may be too ambitious to plan for an uncertain
issue.
NAPCC is yet to consider all the health effects of climate change - only a few diseases
like dengue and malaria are addressed under the disaster management strategy of
NAPCC.
Governments, both at the centre and states is yet to declare an integrated action plan in
the health sector incorporating the emerging health risks due to climate change.
Integrating climate
change and health at the
Operating level
Decision makers at the operating level are “yet to internalize” the scientific information
on climate change and health risks for deciding on the local actions for mitigation and
adaptation.
Doctors and health workers delivering health services are not specifically aware of the
relation between climate change and the emerging health impacts.
Medical curriculum in the country is yet to factor-in climate change as a determinant of
health.
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
!)"34-5"6"7189:;1/<"#*!*="
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"
The health delivery system is yet to be prepared to deal with climate change induced
health impacts.
“Approach” of the
present “health system”
In India, the health delivery mechanism spends more time in treating the conventional
diseases. The approach is primarily “curative” rather than “preventive”. Climate change
related health impacts need more preventive approach and is a public health issue as the
impact is expected to be more on the poorer section of the society.
While a sound public health policy should focus on reduction of preventable diseases,
in India, this philosophy has limited evidence in the health related programmes.
The public policies and systems in India are still saddled by the debate on according
importance and attention between the burden of classical diseases and the emerging
health risks. As on date the planning for emerging health risk is treated as a peripheral
activity.
Actions to increase the awareness among communities and strengthen the participation
of communities for “preventing” diseases have less-than-required emphasis.
The present approach of curative care is not adequate to increase the preparedness of
the system for fighting climate induced health risks.
Source: (Roy & Netinder, 2010)
Table 10 Climate Change and Health in India: Gap Analysis
Disease Surveillance
System
In India the system of gathering consolidated information about incidence of
diseases may be less than efficient. A good monitoring and evaluation system is
the need of the hour disease records are to be managed efficiently to generate
early warning systems. The information base can be used to identify the
emerging health risks
Manpower in the health
sector and Psyche of the
population
Adequacy of training/awareness among the health workers at the grass-root for
delivery of public health is questionable. The number of trained doctors/nurses
working at the government facilities at the grass-root level is far from adequate.
Poor people spend money and end up visiting a quack.
Citizens are oblivious of the fact that health is a right
Illiteracy and poverty leads to faulty health-seeking behavior among the
population. Myths and misconception leads to reliance on religious customs for
cure.
Poor rural population is often afraid of approaching the organized healthcare
facility as they are thwarted by the rude behaviour of the doctors and nurses.
Institutional Capacity
within the country
The issue of the absence of “inter-sector convergence” is an important barrier
and there may be less than adequate collaboration among ministries and
departments (meteorology, social welfare, rural and urban development,
veterinary, water and sanitation, health, environment, etc.) in preparing the
health sector in India to combat the climate induced health risks. Ministries are
yet to identify their own contributions to design a prepared health system in the
perspective of climate change.
Urban India, primarily, is increasingly serviced by the private players in the
#*"
"
health sector; there is little confidence in the government infrastructure for
health care.
Healthcare is becoming increasingly less affordable to large number of
population.
Health insurance is not supported by the state. Health insurance for the rural
poor has just started but the coverage, as yet, is low.
Access to health services best in the city, poorest in the rural areas. Often,
factors like difficult terrain, insurgency, etc. pose a challenge in delivering
health facilities
Rural areas in the country face serious constraint in the form of inadequate
availability of medicines
Availability of doctor per capita is miserably low; so also is the availability of
hospital beds (and other such infrastructure)
Absence of a desired
“Bottom-Up” Approach
Stakeholders, particularly, at the grass-root are, very often, not consulted while
devising strategies and policies for the health sector.
The current system may be plagued with a “one size fits all” approach for
delivery of health care in India. There are both spatial and temporal variations
in the problems. Specific regional problems are to be analyzed and understood
and the results to be used by policymakers in addition to involving
communities for policy design .Hence, innovation has to be inbuilt in the policy
design.
Health care system is yet to recognize that morbidity and mortality have to be
managed through the interplay of multiple disciplines.
Absence of region
specific information and
evidence
There are many districts in India which are experiencing temperature and
precipitation change for the past few years. What have been the effects (of such
change) on the vector borne diseases? Is there a chronic heat effect? Is there an
evidence of child mortality/ neo natal mortality with temperature rise? Are
there evidences of the emergence of new viruses due to temperature rise?
Evidences and case studies are missing.
One cannot say how the public health system should respond to the emerging
health risks if one does not know with more confidence on exact cause-effect
relationship between climate change and health with a region-specific focus.
Prospective studies on the health effects of climate change are yet to be
commissioned. Answers to some of the following questions are still awaited:
(a) What will be the health impacts of extreme heat /flood in the future (say,
2030/2050/2080)?
(b) What will be the vulnerability profile of the districts and regions as a
consequence of different scenarios of climate change?
(c) What could be the adaptation strategies? What technological solutions are
possible?
Research needs to be directed at finding out “local” evidence(s) and possible
impacts. It is only then policy makers can be convinced and proper planning
will be possible.
Also there is need for evidence based policy briefs for different levels of
government(s) for initiating action for mitigating health effects of climate
change and scaling up adaptation capabilities.
As on date, there exists gap in communication between scientific research and
communities at the grass-root. This gap needs to be bridged. Findings from
scientific research (relation between climate change and health) are to be
communicated to the communities in the language they understand.
Political will
Politicians gain from planning for the immediate problems showing immediate
results in economic gain. More attention, therefore, is directed towards the
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conventional problems rather than new emerging issues with uncertain outcome
“Prevention” and
“Climate Change” not
top of the mind recall
among the population
A large proportion of the population does not recognize the preventive
measures. Further, common people are yet to recognize and realize the threat to
health posed by climate change.
Source: (Roy & Netinder, 2010)
ALTERNATE HEALTH POLICY REGIME AND SUSTAINABLE DEVELOPMENT IN INDIA
Health is often regarded as capital as it increases human productivity and thus augments income
generation capacities and social welfare. It is therefore imperative to ensure both public investment in
health infrastructure and management, as well as private investment for the maintenance of personal
health. In literature, investment in both public and private health is advocated to ensure sustainable
development in the long run.
In India, for a very long time, an alternative health system that stresses on man-nature interaction
AYUSH, has prevailed. Over centuries, this system had effectively provided health care to a large section
of the population. More a preventive medical regime, the popularity of AYUSH can be attributed to its
low cost and its “individual” or one-to-one form of treatment (Moreno Leguizamon, 2005).
Post 1947, the Indian health policy, encouraged by the western system of modern pharmaceuticals, had
focused more on a curative health system. Consequently, with policy and institutional patronage, a
curative regime with appropriate supply chain and network penetrated fast to compete away the
traditional preventive system. Further, with the advancement of medical science, a number of wonder
drugs that effectively treated hitherto incurable diseases flooded the market providing mass scale relief for
specific illness. Consequently, the traditional health management systems were marginalised. However,
climate change induced health impacts have revived the demand for investment in preventive healthcare
as a possible adaptation policy (Haque, Louis, Phalkey, & Sauerborn, 2014). Research shows that
indigenous medical systems provide safe and effective therapies, are readily accessible even in remote
rural areas and, are more capital and energy efficient than modern pharmaceuticals as the former are
based on locally available resources that requires little transport and preservation costs (Carlson, 2000).
To provide preventive care to a large population it is necessary to develop a holistic health care medical
system. The challenge is to revive the traditional medical systems, make them less individual oriented and
integrate them with the public health system. To do this, it is necessary to understand the science behind
such systems as this will help mainstream the traditional systems in the policies designed for preventive
care. A holistic preventive health care system may come into existence through a successful co-existence
of two regimes - the traditional health care systems and modern pharmaceuticals.
In India, the delivery of public health rests on the health workers working at the community level - the
Auxiliary Nurses & Midwives, ASHA19 Workers, etc. Most health workers in India are not much aware
of the impacts of climate change on health and are hence not skilled enough to prepare communities
under their care to cope with such impacts and reduce their vulnerability. Preparing a plan for imparting
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
!+"ASHA: Accredited Social Health Activists are trained female health workers who act as an interface between the
community and the public health system
##"
"
training to health workers on climate change, its health impacts and possible coping strategies is,
therefore, necessary. Furthermore, community participation in developing adaptation plans and capacity
building are key components in building climate resilience in rural and economically backward areas that
are highly vulnerable to the impacts of climate change. Capacity building through knowledge
dissemination and training at the community level is essential to achieve a prepared and responsive health
system with an inbuilt principle of preventive care.
In India the apparent dichotomy between “climate change” and “health” (at the policy level) exists
because there are serious research gaps regarding the exact relation between climate change and possible
health impacts and their care need. Focused research in building up case studies at the local level,
experiments for exploring efficient and effective coping strategies and adaptive capacities are required to
initiate actions at the policy level. Not only historical studies but also prospective studies are required to
map disease data and climate data for predicting the likely scenario in the future. This is because response
cannot be formulated without taking into account evidence. Also, such research is required to develop an
“early warning system” in order to increase the preparedness of all the stakeholders exposed to the risk of
climate change induced health risks. Some recent experiences of extreme weather events have brought
into focus the lack of preparednessphysical infrastructure such as water and health testing facilities for
water borne diseases, testing centres to detect new types of diseases, trained medical stuff, preventive
medicine advisory dissemination institutions, etc. Healthcare technology development for rapid detection,
diagnosis and prediction is still at a nascent stage in the country. This enhances vulnerability.
The role of the health administration in health infrastructure management need to be professionally
developed and strengthened in India in order to achieve a comprehensive preventive health service
delivery system. The current regime advocates a skewed healthcare system that lacks in managerial
efficiency. New diseases, mutation of pathogens and allergens, changing disease patterns, increase in the
spatial spread of disease incidence due to the increase in the frequency and intensity of extreme events,
etc. has made it crucial that the managerial aspect of generating quality health services be recognized as a
dedicated action plan. This will mean revisiting existing public health laws such as the District and
Village Health Plans of the National Rural Health Mission (NRHM) program and charting effective
pathways to enforce these regulations. Further, the capacity to provide a holistic health system that
incorporates traditional and modern practices need to be incorporated into the agenda of the institutions
that provide health care in India.
Health is not an isolated issue but is intensely linked with the drinking water quality, sanitation and air
quality both indoor and outdoor. Managing water for drinking purpose and air quality both at public
provisioning level and household level needs special attention. There is also need for technology
development and deployment, and monitoring of health infrastructure and health indicators for human
wellbeing.
Accordingly, a set of action programmes have been considered in envisaging a road map for initiating
actions by the Government of India to integrate health and climate change. The aim of the roadmap is to
promote sustainable effort to combat vulnerability of the health sector in the face of climate induced
health risks. The focused approach, as suggested in the roadmap is not only aimed at improving the
existing public health system but to also generate adequate adaptive capacity to cope with climate change
induced health risks. The suggested approach incorporates “preventive” measures as an integral
#%"
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component and is called National Preventive Health Care Programme (NPHCP). The NPHCP is expected
to generate a set of knowledge that may be used to formulate an “approach programme” for building a
nation-wide National Preventive Health Care System (NPHCS) or National Preventive Health Care
Mission (NPHCM). The goal of NPHCP is to mainstream NHPCS as a planned activity both at the
national and the state levels. NPHCP is a research-driven, goal-oriented and strategic programme that is
envisaged to have three pillars knowledge generation, infrastructure planning, and training. The main
activities under each of these pillars are presented in table 11.
Table 11 Suggested Activities in NPHPCP
Knowledge Generation
Infrastructure Planning
Training
Formation of a nation-wide
network of institutions and
individuals focusing on research
related to the issues in “climate
change and health” in working
groups mode
Linking this network to the
international knowledge and
experience by bringing together
mutually complementary research
/training /technology /knowledge
sharing institutes and pool of
human capital
Developing a collaborative
research capacity for modelling
the local incidence of disease for
designing early warning systems
Building institutional
collaboration for exchange
programmes for students,
researchers,
professionals/bureaucrats, policy
makers
Facilitate preventive health care
through devising a programme
for information management a
data bank capturing climate
parameters, health
outcomes/stresses, hospital data
and provide access to researchers
to this databank for analysis,
decision tool development to help
policy making on a continuous
basis
Preparing a plan and mechanism
for cross country technology
diffusion with an aim to promote
preventive care
Establishing a collaborative
mechanism for development and
deployment of technology for
preventive cure
Preparing risk management
strategy(ies) in the domain of
public health in the developing
country context keeping in view
the size, spread and density of the
population
Creating institutional capacity for
infrastructure including access to
relevant data sets, computing and
communication facilities
Designing a plan to complement
efforts under the various national
missions (in the health and other
sectors) through global
cooperation (for sharing
experiences in different
countries)
Facilitate an improved
understanding and awareness of
the key drivers of health risks
under climate change, especially
among the existing and future
pool of workers delivering health
services in the country
Fostering professional attitude
and incorporating preventive care
in the health system
Building awareness to improve
quality of data - hospital data,
disease data, etc. i.e. all kinds of
epidemiological data
Source: (Roy & Netinder, 2010)
Management of the human capital, of which health is an integral part, has very large externalities besides
private benefits. Given the public good component of health the government’s role cannot be negated. To
augment the Indian health system with the principles of preventive care in the light of climate change
#'"
"
induced health impacts it is required that multiple agencies work in close tandem. A close cooperation
between the ministries will play a crucial role in implementing the programme and mainstreaming it in
the national policy.
Given the vastness and variability of the country like India, there is expected to be variability in the
effects of climate change on health across population groups and geographical areas. Hence, it is
important to formulate “local” studies to develop appropriate and efficient response functions. The control
groups may be decided upon based on the known vulnerability of the regions and/or social groups.
CONCLUSION
There is consensus in climate science literature that climate change will have exacerbated impact on
human health. It provides a scope to enhance preventive actions to combat and minimize the anticipated
adverse impacts on health. Developing nations like India, with low infrastructure facilities, limited
resources, diverse priorities and often with large population are particularly vulnerable to the likely health
impacts of climate change. Public health care strategy for adaptation can be geared towards
mainstreaming preventive indigenous health care methods integrating it with current cure based systems.
This is particularly necessary in countries like India that has a much stratified income-educational and
social categorization and currently not covered by modern cure system. In this scenario, if the diverse
socio-economic structure is neglected while framing future health policies, it will be difficult to impart an
integrated and holistic health care to all social strata.
The objective is to create and integrate health mission that is target driven, policy oriented and action
driven. The traditional Indian health system is largely based on providing preventive health care. Further,
it is relatively cheap and individual based. Integration of these two different health care paradigms can
provide the right kind of approach to addressing health issues in a developing country under the existing
climate change scenario. Once such holistic system is designed based on the bottom up approach, it will
find universal acceptance among all socio-economic classes across nations thus ensuring the future
success and robustness of the health system.
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K-AW9:F89-:"-@"N1F8<"N.A9;985"F:;"XI1/09G1V>"Sports*Medicine,*343!=<"+Y!&>"
eFC9<"^>"7><"4-0SHg?<"[><"7O.1@F0SYbGFO.1<"L><"b18F:51<"X><"6"Q_1HHG8/-A<"b>"3#*!*=>"VN1F8"MACF08"-:"
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Health*Action,*33!*=>"
eFGB<",>"Q><"6"Q_1HHG8/-A<"b>"3#*!!=>"VR-/SCHF01"N1F8",8/1GG"9:"8B1"K-:81I8"-@"49G9:O"b1AC1/F8./1"9:"
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eBF/F<"4>"a><",0B/FAA<"T>"[><"6"^.W1/<"L>"3#*!%=>"VKH9AF81"KBF:O1"6"M:@1089-.G"e9G1FG1G"9:"M:;9F2"
MACH90F89-:G"@-/"N1FH8B"KF/1"T/-?9;1/GV>"Indian*Journal*of*Medical*Research,*138<")'(Y)$#>"
U/FSG-:<"[>"4>"3#**+=>""Managing*the*Health*Effects*of*Climate*Change:*Changing*Patterns*of*Disease*and*
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LF:O-HH9<"^>"a><"e.OOFH<"4><"6",B.SHF<"J>"3#**$=>""Review*of*Healthcare*In*India"."K1:8/1"@-/"X:h.9/5"9:8-"
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LF/O<"J><"eB9AF:<"4>"K><"ZBF88F0BF/5F<",><"6",B.SHF<"T>"4>"3#**+=>"Ve1?1H-CA1:8<"<PFHF/9F"F:;"J;FC8F89-:"
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NFh.1<"P>"J><"^-.9G<"a>"4><"TBFHS15<"4><"6",F.1/W-/:<"4>"3#*!'<"U1W/.F/5=>"ViG1"-@"b/F;989-:FH"P1;909:1G"8-"
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MTKK>"3#**!=>"Intergovernmental*Panel*on*Climate*Change:*"Climate*Change*2001:*Synthesis*Report".""
MTKK>"3#**!=>"Intergovernmental*Panel*on*Climate*Change:"Climate*Change*2001:Impact,*Adaptation*
and*Vulnerability",Contribution*of*Working*Group*II*to*the*Third*Assessment*Report*of*the*IPCC."
KFAW/9;O1"i:9?1/G985"T/1GG<"iQ>"
MTKK>"3#**(=>"Intergovernmental*Panel*on*Climate*Change:*"*Climate*Change*2007:Impacts,*Adaptation*
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IPCC."KFAW/9;O1"i:9?1/G985"T/1GG<"iQ>"
MTKK>"3#*!%=>"Intergovernmental*Panel*on*Climate*Change:*"Climate*Change*2013:*The*Physical*Science*
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i:9?1/G985"T/1GG<iQ>"
MTKK>"3#*!'=>"Intergovernmental*Panel*on*Climate*Change:"Climate*Change*2014:*Impacts,*Adaptation,*
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Fifth*Assessment*Report."KFAW/9;O1"i:9?1/G985"T/1GG<"iQ>"
[F9:<"7><"6",F:;11C<",>"3#**+=>""White*Paper*on*HealthCare*Sector*"."b>"J>"TF9"PF:FO1A1:8"M:G898.81>"
Q_1HHG8/-A<"b><"^1AS1<"Z><"6"N5F8<"j>"3#*!!=>"VM:0/1FG1;"R-/SCHF01"N1F8"XIC-G./1";.1"8-"KH9AF81"KBF:O12"
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e1?1H-CA1:8"9:"JG9F"F:;"8B1"TF09@90"41O9-:V>"Asian-Pacific*Newsletter*on*Occupational*Health*
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^.W1/<"L><"6"P0L11B9:<"P>"3#**)<"7-?1AW1/=>"VKH9AF81"KBF:O1"F:;"XI8/1A1"N1F8"X?1:8GV>"American*
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PF_/F<"[>"T><"6"L./<"J>"3#**+=>"VKH9AF81"KBF:O1"F:;"N1FH8B2"RB5"GB-.H;"M:;9F"W1"K-:01/:1;cV>"Indian*
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PFHH<"4>"Q><"L.C8F<"J><",9:OB<"4><",9:OB<"4>",><"6"4F8B-/1<"^>",>"3#**&=>"VRF81/"41G-./01G"F:;"KH9AF81"
KBF:O12"J:"M:;9F:"T1/GC1089?1V>"Current*Science,*90<"!&!*Y!&#&>"
PF8B11<"J><"jWF<"[><"6"4-G1<"J>"3#*!*=>"VKH9AF81"KBF:O1"MACF08G"-:"R-/S9:O"T1-CH1"38B1"NjbNJT,"
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F:;"Z-;5YP9:;V>"Economic*and*Political*Weekly,*403%*=<"CC>"%%*#Y%%!*>"
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7JbKjP>"3#**'=>""India's*Initial*National*Communication*to*the*United*Nations*Framework*Convention*
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7JbKjP>"3#*!#=>""India:*Second*National*Communication*to*the*United*Nations*Framework*Convention*
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Health*Policy*and*Planning,*183%=<"#'+Y#&*>"
T181/G<"e>"N><"mFfW10S<"J><"6",BF/AF<"4>"3#**#=>"\Z1881/"N1FH8B",5G81AG"@-/"M:;9FnG"T--/2"U9:;9:OG<"
J:FH5G9G<"F:;"jC89-:G]>"bB1"R-/H;"ZF:S<"RFGB9:O8-:"eK>"
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THF::9:O"K-AA9GG9-:"-@"M:;9F>"3#*!%=>""Press*Note*on*Poverty*Estimates,*2011-2012"."L-?1/:A1:8"-@"
M:;9F<"THF::9:O"K-AA9GG9-:>"
4-;/9O.1fY^^F:1G<"[>"P><"eFGB<",>"4><"e1O-AA1<"j><"P.SB-CF;B5F5<"J><"6"L.BFY,FC9/<"e>"3#*!!=>"VKB9H;"
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4-5<"[>"3#*!*=>""Extreme*Events,*Water*Resources,*Status*of*Human*Health,*Livelihood:An*Adaptation*
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4-5<"[><"6"7189:;1/<"L>"3#*!*=>""Report*of*the*Study*Developing*a*Roadmap*for*Climate*Change*and*
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represented*by*The*Embassy*of*Sweden,*New*Delhi*under.""
4-5<"[><"KBFS/FWF/85<"J><"P.SB-CF;B5F5<"Q><"6"QF:_9HFH<"P>"3#*!!=>"VKH9AF81"KBF:O1<"N1F8",8/1GG"F:;"^-GG"
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X0-H-O90FH"X0-:-A90G"3M7,XX="Z91::9FH"K-:@1/1:01>"N5;1/FWF;>"
4-5<"[><"KBF881/_11<"Z><"6"ZFGFS<",>"3#**)=>"Vb-EF/;G"F"K-AC-G981",.G8F9:FW9H985"M:;1I2N-E"F/1"8B1",8F81G"
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7F89-:GV>"M:"Economic*Development"3CC>"&(Y!*$=>"T1F/G-:"X;.0F89-:>"
i7eT>"3#*!'=>""Human*Development*Report".""
i7MKXU>"3#**+=>"PF:FO1A1:8"T/F08901G"@-/"KB9H;B--;"e9F//B-1F"9:"M:;9F2",./?15"-@"!*"e9G8/908G>"i7MKXU>"
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RNj",XJ4j>"3#**(=>"World*Health*Organization:"Climate*Change*and*Human*Health*in*Asia*and*the*
Pacific:*From*Evidence*to*Action":*Report*of*the*Regional*Workshop.""
RNj",XJ4j>"3#**(=>"World*Health*Organization:"Climate*change*and*its*Impact*on*Human*Health":*
National*Workshop.""
3:>;>=>"World*Health*Statistics*2013."R-/H;"N1FH8B"j/OF:9fF89-:>"
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