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Council on Energy, Environment and Water Integrated | International | Independent
REPORT
Making India’s Healthcare Infrastructure Climate Resilient
A District-level Risk Assessment Framework
25 October, 2024 | Climate Resilience
Ahana Chatterjee, Shreya Wadhawan, Dr Vishwas Chitale and Pallavi Dhandhania

Suggested Citation: Chatterjee, Ahana, Shreya Wadhawan, Vishwas Chitale and Pallavi Dhandhania. 2024. Mainstreaming Climate Risk Assessment for Healthcare Facilities in India: A District-level Assessment. New Delhi: Council on Energy, Environment and Water

Overview

This study highlights the increasing vulnerability of India's healthcare infrastructure to extreme climate events, particularly floods and cyclones. India is the seventh most vulnerable country to the impacts of extreme climate events, with over 200,000+ healthcare facilities, many of which face significant risks from extreme weather events. In contrast, India’s healthcare expenditures observe steady growth, with a 14 per cent increase recorded between 2023 and 2024. The report thus underscores the necessity for granular, district-level climate risk assessments to build the resilience of these critical assets. The study introduces a novel scalable risk assessment framework for climate-proofing critical infrastructure, focusing on India’s healthcare facilities. By utilising the framework, the study aims to prioritise healthcare facilities for adaptation, ensuring resilient infrastructure investments and enhanced disaster preparedness. It also presents a use case by applying the framework in Maharashtra and illustrates the need for immediate and long-term action to protect healthcare facilities.

Key Findings

  • Climate Risk in Maharashtra: As per CEEW’s analysis, 11% of healthcare facilities in Maharashtra are currently at high risk from floods and cyclones, primarily in coastal districts like Raigad and Mumbai, requiring urgent action.
  • Projected Risk by 2050: 33% of Maharashtra's healthcare facilities are projected to be at high risk by 2050, due to increasing extreme weather events.
  • Adaptive Capacity: 52% of healthcare facilities in Maharashtra have moderate to high adaptive capacity, but the remaining 48% need significant improvements.
  • Immediate steps such as structural audits, workforce capacity building, and investment in infrastructure maintenance are crucial to improving resilience in high-risk districts. At the same time, long-term planning is required in districts with healthcare facilities with low adaptive capacity and increasing hazard occurrence.
  • The study introduces a Healthcare Facility Resilience Checklist to mainstream on-ground risk assessments in coordination with the National Programme on Climate Change and Human Health (NPCCHH).

 


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“As climate-related disasters intensify, safeguarding healthcare infrastructure is not just about protecting buildings but about ensuring the resilience of the systems that keep communities healthy and secure. By integrating climate risk assessments into the core of healthcare planning, we can turn vulnerability into strength and ensure our facilities remain operational when they are needed the most."

Executive summary

According to the World Meteorological Organization (WMO), Asia suffered more than 81 climate- and water-related – or hydro-meteorological – disasters in 2022, causing economic damage of more than USD 36 billion (WMO 2022). India ranks as the seventh-most vulnerable country with respect to climate extremes (Germanwatch 2020), with 80 per cent of its population residing in districts that are highly vulnerable to the impacts of extreme hydro-meteorological disasters such as floods, droughts and cyclones (Mohanty and Wadhawan 2021). The occurrence of such disasters can trigger a series of cascading and compounding impacts. Rapid-onset disasters such as floods and cyclones cause substantial physical damage to infrastructure assets, severely impacting critical assets such as road networks, power systems, and healthcare facilities and, therefore, magnifying disaster risks. According to the State Bank of India (SBI) ECOWRAP report (2023), India suffered economic losses of INR 12 trillion due to floods and storms between 1900 and 2023 (State Bank of India 2023). Further, India’s transport and power infrastructure sectors are estimated to suffer an annual loss of INR 1.5 trillion due to extreme weather events such as floods and cyclones (World Bank 2019).

Additionally, like most countries in the Global South, India’s approach to disaster management focuses on response, recovery and relief rather than anticipatory action to reduce future losses (UNDRR 2023). Following the National Disaster Management Act 2005, India’s disaster management plans, policies and guidelines emphasise preparedness and recovery over mitigation and adaptation. Furthermore, existing governance complexities pose challenges in this cross-cutting sector of infrastructure resilience. The development of most critical infrastructure assets falls under the purview of the states, while disaster risk reduction and climate adaptation largely remain a topic managed by national-level policy-makers. This hinders a holistic approach to resilient infrastructure development.

To develop context-specific adaptation solutions, India must identify and quantify the physical risk at a granular level. This calls for comprehensive risk assessment across critical infrastructure sectors, which can generate scientific evidence for administrators, policymakers, and investors to enhance decision-making processes and prioritise adaptation planning. Such a risk assessment will help policymakers prioritise spending on critical assets and streamline the implementation of adaptation measures, thus safeguarding current and future infrastructure investments. To bridge this gap, we have developed a first-of-its-kind, unified, and scalable risk assessment framework for climate-proofing critical infrastructure against extreme floods and cyclones.

Building on the Intergovernmental Panel on Climate Change (IPCC) definition of risk, the framework has been designed to serve a dual purpose: (a) First, it quantifies and maps the risk to critical infrastructure geospatially at the district level. (b) Second, drawing insights from the risk assessment, it identifies risk drivers and proposes context-specific adaptation solutions that can be implemented at varying scales. This is crucial for prioritising infrastructure at risk, streamlining adaptation solutions through a needs-based approach, and minimising redundant investments.

1 Critical infrastructures refer to the physical structures, facilities, networks, and other assets that provide services indispensable to the social and economic functioning of society and are necessary for managing disaster risk (CDRI 2023).

A scientific risk assessment is the first step in climate-proofing. Risk mapping helps strengthen climate resilience by assessing the overall climate change risk at a granular scale. Therefore, the framework serves as a guiding mechanism for selecting the most suitable adaptation measures for sustainable infrastructure development and helps prioritise the implementation of adaptation actions.

This report illustrates a case study on healthcare facilities, which play a pivotal role in safeguarding public health, bolstering economic resilience, and enabling efficient disaster response. India has more than 200,000 healthcare facilities (see Fig ES1). These comprise government facilities (primary, secondary and tertiary healthcare facilities) as well as private ones that are empanelled under government schemes or programmes such as Ayushman Bharat, Pradhan Manti Jan Arogya Yojana (PMJAY), Central Government Health Scheme (CGHS), etc. Therefore, a significant percentage of the Indian population depends on these healthcare facilities, many of which might be facing risks due to extreme weather events or are likely to face them in the foreseeable future.

Figure ES1 India has more than 200,000 healthcare facilities, many of which are at risk due to extreme weather events*

ES1

 

On the other hand, the healthcare sector in India has also witnessed a 14 per cent increase in expenditure over the past year, underscoring the rising importance of public healthcare and social security in ensuring universal health coverage (PIB 2024). This underlines the need for granular risk assessments for healthcare infrastructure, to enable risk-informed investments and context-specific solutions.

Addressing this need, the devised framework for climate-proofing healthcare facilities evaluates multiple indicators to assess each risk component to healthcare facilities and collates the risk score at a district level. In alignment with the IPCC formula, the framework defines risk to critical infrastructure as a function of three variables:

  • i. Hazard: The historical or projected occurrence of floods and cyclones in a district;
  • ii. Exposure: The density of critical infrastructure assets in the district;
  • iii. Vulnerability: The likelihood of critical infrastructure assets within the district to be adversely affected by extreme floods or cyclones.

The risk score, represented on a scale from 0 to 1, is estimated using a composite index-based methodology that combines the scores of each indicator in alignment with the IPCC formula for risk. ES Figure 2 outlines a snapshot of the risk-assessment framework.

ES Figure 2: Framework for climate-proofing healthcare facilities

Es figure 2

 

The proposed framework was further tested through a pilot study in Maharashtra, which ranks third among the Indian states in terms of vulnerability to extreme hydro-meteorological disasters (Mohanty and Wadhawan 2021). The state houses more than 17,000 public healthcare facilities, which might face significant impacts due to the increasing occurrence and intensity of extreme weather events (EWEs) (PMGSY n.d.). This poses a substantial risk to the functioning of healthcare facilities during disasters. Maharashtra also houses the most significant economy out of all the states in India, accounting for 13.3 per cent of the country’s Gross Domestic Product (GDP) (Government of Maharashtra 2023). The Interim Budget 2024–25 has also proposed allocating nearly INR 10,000 crore to improving healthcare facilities in the state. This underscores the need to safeguard the state’s economy and upcoming investments, which must be safeguarded from disaster-induced losses to ensure maximum utilisation (TERI 2024).

Maharashtra showcases exemplary steps to enhance the adaptive capacity of its healthcare system against the growing threats posed by climate change. The state ranks 4th as per Niti Aayog’s Health Index, which assesses the performance of healthcare systems across the country by tracking the improvement in key health outcomes (Niti Aayog 2022). Maharashtra has also submitted a revised version of their State Action Plan on Climate Change and Human Health (SAPCCHH) for 2022-2027, laying out a comprehensive roadmap to tackle climate-induced health risks. Additionally, regional initiatives such as launching the Maharashtra Tertiary Care and Medical Education Sector Development Program in Raigad and Sindhudurg districts aim to strengthen tertiary healthcare services and ensure improved access to quality care (ADB 2023). These initiatives are especially critical as the state faces more frequent and intense extreme weather events, such as heavy rainfall, heatwaves, and cold waves, which heighten the risks of vector-borne diseases. Thus, by prioritising capacity-building in healthcare infrastructure, Maharashtra is equipping its health systems to withstand climate-induced shocks better and continue serving vulnerable communities (ADB 2023).

However, our key findings suggest that further action is necessary to safeguard healthcare facilities in the state, especially to reduce physical risks posed by increased extreme weather events such as floods and cyclones.

Key findings from Maharashtra

Risk Level of Healthcare Facilities in Maharashtra

  • 89 per cent of healthcare facilities in Maharashtra are not at immediate risk from floods and cyclones. However, over 1,700 healthcare facilities in Maharashtra, representing approximately 11 per cent of the total healthcare facilities in the state, are currently at high risk from floods and cyclones and require immediate action (ES Figure 3). This is based on historical trends of flood and cyclone occurrence as observed between 1990 and 2022, the exposure level of healthcare facilities in each district, as well as their level of vulnerability. The at-risk facilities are concentrated in four districts: Raigad, Mumbai Suburban, Mumbai, and Nagpur. These districts experience frequent extreme floods and cyclones, and 70–80 per cent of their healthcare facilities are located in highly flood and/or cyclone-prone geographical locations, therefore magnifying the risk level.
  • Over 5,500 healthcare facilities in Maharashtra, representing 33 per cent of the total healthcare facilities in the state (across 14 districts), are likely to experience high risk from floods and/or cyclones by 2050. This is considering increasing hazard occurrences and the existing capacity of the state's healthcare infrastructure. Healthcare facilities in these districts have underlying vulnerabilities stemming from low structural and functional capacities and low expenditure on maintenance and upgradation. Such vulnerabilities can magnify disaster risk, as annual heavy rainfall days are projected to increase by an average of 15 per cent between 2023 and 2050 (CEEW 2024).

Figure ES3 Eleven per cent of healthcare facilities across four districts in Maharashtra are currently at high risk of floods and cyclones

ES3

 

Adaptive Capacity of Healthcare Facilities in Maharashtra

  • Approximately 52 per cent of healthcare facilities in Maharashtra have moderate to high adaptive capacity. The adaptive capacity score is representative of factors such as the adequacy of the healthcare system in the district, preparedness of facilities against extreme weather events, expenditure on structural upgradation, etc. Mumbai, Sindhudurg, and Ratnagiri recorded the highest administrative capacity, indicating that healthcare facilities in these districts are better prepared and trained for anticipatory action. Nashik, Aurangabad, Gadchiroli, and Pune have robust DDMPs that contain relevant structural and non-structural strategies for improving healthcare resilience against extreme climate events. These districts also recorded higher annual expenditures on healthcare systemic strengthening (NHM PIP Budget 2023). Additionally, Pune and Kolhapur house the largest number of NQA- and NABH-accredited hospitals in the State, which are more operationally efficient. Healthcare facilities in these districts can serve as leading examples for increasing adaptive capacities across the State.
  • Despite exemplary efforts, healthcare facilities across 19 districts in the state observe low adaptive capacity. This comprises approximately 8,400 healthcare facilities, representing 48 per cent of the total. Facilities in these districts can improve their structural strength by increasing their expenditure on structural upgradation. This can be achieved by utilising funds under the National Health Mission. Inspiration can be drawn from districts Nashik and Thane, where more than INR 10 Crore has been spent for structural upgradation in each district only in the last financial year (NHM PIP Budget 2023). Healthcare facilities in these districts can also improve their functional capacity by increasing the number of NABH and NQAS-accredited hospitals. Additionally, the preparation of hospital disaster management plans that focus on managing the impacts of extreme weather events can increase administrative preparedness.
  • Healthcare facilities located in districts with low adaptive capacity scores and high occurrences of floods and cyclones must take immediate action. These short-term actions can be structural audits of healthcare facilities, capacity building of the healthcare workforce, increased investments in the operation and maintenance of facilities, etc. Facilities in districts that observe a low adaptive capacity and a growing trend in hazard occurrence should undertake planned action by conducting asset-level risk assessments and identifying infrastructure corridors in safe locations (see Figure ES3).

Figure ES4: Eleven per cent of healthcare facilities across four districts in Maharashtra are currently at high risk of floods and cyclones

es4

It is important to note that even healthcare facilities in well-performing districts observe increasing risk levels, owing to the increasing frequency and intensity of extreme weather events. Therefore, sustained action is necessary to ensure that the adaptive capacity of healthcare facilities in these districts steadily increases over the years. Maharashtra can thus build the resilience of the state’s healthcare facilities in the long term and safeguard crucial investments in healthcare infrastructure. The framework can accelerate states' efforts by identifying these drivers, streamlining investments, and reducing damage and losses. By implementing the framework, Maharashtra can be a leading example for other states. Using insights from the Maharashtra use case, the study suggests national, state, and district-level recommendations to reduce the risks to healthcare facilities nationwide.

Key recommendations
  • The National Programme on Climate Change and Human Health (NPCCHH) should identify characteristics of healthcare infrastructure resilience: Currently, the guidelines of the NPCCHH on Green and Climate Resilient Healthcare (MoHFW 2023) focus more on climate change mitigation than adaptation. The NPCCHH guidelines must be revised to include specific adaptation measures to align with the objectives of the National Health Policy, which emphasises the importance of resilient healthcare infrastructure, especially during extreme climate events such as floods and cyclones. This report presents a checklist to assess asset-level preparedness and quantify healthcare facility resilience, which can be directly incorporated into the existing NPCCHH guidelines.
  • District health departments must assess the physical risk and enhance the resilience of healthcare facilities at the local level: Physical risk assessment helps identify healthcare facility vulnerabilities, aiding the section of risk-informed solutions. However, such an assessment must be conducted at the district scale, as local administrators will be aware of limiting factors such as cost, time, and resource availability, which will enable them to identify the most feasible solutions. Therefore, district-level health departments and local administrators should prioritise adaptation solutions based on on-ground realities to enhance solution specificity and optimise resource utilisation. An expert opinion survey was conducted to explore the influence of such parameters on the feasibility and impact of the selected adaptation strategies.
  • State health departments should mandate all the districts to assess risks at the asset level: To accelerate action, state health departments should coordinate with stakeholders to define roles, set yearly targets, and monitor progress against key performance indicators (KPIs). By creating an inventory of data on climate-proofing healthcare infrastructure, they can track progress, realign objectives, and allocate funds based on priorities and the state healthcare budget.
  • The Indian Public Health Standards(IPHS) should be expanded to monitor the resilience of healthcare facilities: The IPHS (MoHFW 2022), under the National Health Mission (NHM), can be expanded to include other factors that capture healthcare facilities’ adaptive capacity. Mapping hospital locations will enhance the existing hospital database and complement the IPHS Hospital Infrastructure Layouts released in 2022 (MoHFW 2022). Additional data on building height, storeys, area, age, and maintenance records from district administrators should be used to conduct asset-level risk assessments to determine whether healthcare facilities are built and maintained in compliance with IPHS. This geospatial dataset can complement the IPHS. The Ministry of Health and Family Welfare (MoHFW) should invest in an online portal to enhance the management of healthcare infrastructure by using data-driven decision-making. District health administrators should be able to upload real-time status data to this portal, enabling continuous monitoring of healthcare facility resilience in line with the IPHS standards. Integrating these functions into a unified national platform would support more efficient and effective oversight of healthcare facilities.
  • The National Health Mission (NHM) should catalyse climate finance for healthcare infrastructure resilience: The NHM offers financial assistance to states to improve the structural integrity of healthcare infrastructure. However, increased investments are needed to accelerate risk-informed decision-making and enhance the resilience of healthcare systems. Therefore, it is imperative to utilise innovative finance mechanisms to boost the volume of funds available.
FAQ's

Frequently Asked Questions

  • What is a climate risk assessment?

    A climate risk assessment is a systematic process used to evaluate the potential risks posed by climate change to various sectors, communities, or regions. It involves identifying, analysing, and prioritising the risks arising from climate-related hazards such as extreme weather events (floods, droughts, heatwaves) and long-term shifts in temperature or precipitation patterns. The Intergovernmental Panel on Climate Change (IPCC) defines climate risk is the potential for negative consequences on society or ecosystems from climate change and defines it as a function of three components: hazard, exposure and vulnerability. A climate risk assessment evaluates the potential impacts of these climate hazards on a system by quantitatively measuring each of the three risk components.

  • What does critical infrastructure mean?

    Critical infrastructure refers to the “physical structures, facilities, networks, and other assets that provide services that are indispensable to the social and economic functioning of society and are necessary for managing disaster risk.” Further, critical infrastructures are identified as systems with heightened vulnerability to disruptions, which can lead to cascading and compounding effects in cases of failure. Therefore, to maintain the continuity of essential services, especially during extreme events and disasters, it is paramount to enhance the resilience of critical infrastructures.

  • Why do healthcare facilities need a climate risk assessment?

    Healthcare facilities need a climate risk assessment to ensure they can continue to deliver essential services in the face of climate change. As climate impacts become more frequent and severe, healthcare systems are particularly vulnerable due to their critical role in protecting public health and providing vital services during extreme climate events. Primary healthcare facilities act as first responders, while secondary and tertiary facilities offer specialised care. However, extreme climate events can put healthcare facilities at risk of several adverse impacts. Physical damage to hospital structures and medical equipment can disrupt service delivery and functioning, leading to more casualties during a disaster. A climate risk assessment can help identify healthcare facilities at risk from extreme climate events and identify key drivers. Therefore, it is imperative to safeguard healthcare facilities from current and future climate risks to ensure that their failure does not magnify disaster risks.

  • What does climate-proofing mean?

    The term ‘climate proofing’ has evolved over the years, and many global organisations have provided different interpretations and definitions for this term. As per the latest definition, ‘climate proofing’ is means (i) a process that aims to identify risks that an investment project may face as a result of climate change and to reduce those risks to levels considered to be acceptable and (ii) a measure aimed at mitigating the climate risk to which a project is exposed.”

  • How do we measure infrastructure resilience?

    Measuring infrastructure resilience involves evaluating how well a system, building, or network can withstand, adapt to, and recover from disruptive events such as natural disasters, climate change impacts, or human-induced hazards. A resilient infrastructure system not only resists damage but also recovers quickly and continues to function. While no universally accepted definition quantifies infrastructure resilience in the face of climate change, it is directly related to factors such as the quality of infrastructure, everyday operations including how well the infrastructure works before a disaster, the quality of emergency plans and response, how effectively information is shared during a crisis, the cost of restoring services after an event, etc.

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