Adapting India’s Health System to Extreme Heat: A Policy Agenda for Clinical, Infrastructural and Financial Preparedness
Contributors
Dr. Indu K. Murthy (Centre for Study of Science, Technology and Policy (CSTEP)); Dr. Hemang Shah (Children’s Investment Fund Foundation (CIFF)); Shalu Agrawal and Dr. Vishwas Chitale (Council on Energy, Environment and Water (CEEW)); Dr. Satchit Balsari (Harvard Medical School); Kartikeya Bhatotia (Harvard University, Lakshmi Mittal and Family South Asia Institute); Madhav Joshi and Dr. Priyamvada Chugh (India Health Fund); Dr. Soumya Swaminathan and Priyadarshini Rajamani (M. S. Swaminathan Research Foundation (MSSRF)); Dr. K. Srinath Reddy and Dr. Rajshankar Ghosh (Public Health Foundation of India (PHFI)); Dr. Bhargav Krishna (Sustainable Futures Collaborative); Aaran Patel, Aarushi Shah, and Dr. Nitya Mohan Khemka (The Nand & Jeet Khemka Foundation).
The hidden health crisis of heat
Extreme heat isn’t just uncomfortable, it’s deadly. Heat-related mortality among older adults increased by ~68% in the last two decades. Heat stress poses a significant public health risk, contributing to increased incidence of cardiovascular[1] , renal[2] and respiratory conditions, mental health disorders such as anxiety and depression[3] , adverse pregnancy outcomes, and a rise in violence[4] . Yet, many of these heat-linked impacts, and in extreme cases, deaths slip under the radar, misdiagnosed as heart failure, and the true case numbers never surface. The number of people facing the adversity of extreme heat is growing exponentially. For those over 65 years, heat-related deaths have jumped a staggering 85% between 2000–2004 and 2017–2021[5] . And climate change is further exacerbating the toll. A report suggests that half of the world’s population endured at least one extra month of extreme heat due to climate change[6] . In South Asia, if temperatures cross the 2°C threshold, heat-related deaths could skyrocket by 370% by 2030[7] . Another statistic shows that Asia accounted for nearly 45% of global heat-related deaths between 2000 and 2019, and extreme heat-induced health impacts remain a significant climate risk[8]
The scorching reality in India
The picture in India is no different; heatwaves and prolonged excess heat conditions are striking harder, longer and more frequently, month on month, and year on year. This year, India experienced its first heat wave in February, the hottest February in 125 years. It was also a month where most Indian states saw nighttime temperatures at least 1°C above normal at least once[9] . An analysis from Council on Energy, Environment and Water (CEEW) showed that more than 57% of Indian districts, home to nearly three-quarters of the country’s total population, are at high to very high heat risk. Heat waves are also already causing premature deaths, with one study across 10 major cities counting over 1100 deaths annually from heatwaves based on current definitions[10]. Co-exposures to heat and air pollution are compounding the risk of ill-health and premature death further across our major cities[11]. With underprepared and overburdened health systems and a humongous population, India stands on dangerously thin ice–or rather, blistering hot ground. The stakes of inaction are very high.
There’s no time to waste
Tools – like the Climate Hazards and Vulnerability Atlas of India[12] and Heat Action Plans (HAPs)[13]–are being rolled out by states, cities and districts, based on the National Disaster Management Authority (NDMA) guidelines. These early moves are promising, but they’re not nearly enough owing to their low population coverage, poor understanding of vulnerability, lack of legal foundations, limited state capacity, and scarce funding. A lot more needs to be done to address this rising challenge[14].
This perspective piece outlines seven actionable, evidence-backed solutions to help us beat the heat – rooted in insights from the session “Towards Resilient Health Systems – Health System Resilience in a Warming World: Clinical, Infrastructural and Financial Preparedness” at the India 2047: Building a Climate-Resilient Future conference[15] .
1. Powering Up Primary Care – The First Line of Heat Defence
When the mercury soars, our primary healthcare facilities – the frontlines of India’s health system – must be able to anticipate, prepare for and respond appropriately. Medical workers at the grassroots must be fully equipped to act on early warning alerts, protect at-risk groups, and prevent adverse outcomes due to extreme heat. Preparedness towards extreme heat must be integrated into their routine operations and outreach. For instance, a heatwave alert to community health workers could initiate efforts for community outreach across villages and city slums through door-to-door drives, phone alerts for residents, urging people to hydrate, stay shaded, and looking out for the elderly and at-risk individuals. Or another scenario where each summer, frontline workers launch tailored health promotion campaigns in local languages, teaching communities to spot signs of heat-related illnesses, encouraging oral rehydration, and adjusting routines to stay safe during heatwaves.
Powering up primary care also includes making the infrastructure itself heat resilient – setting up “cool rooms” or shaded waiting areas, ensuring uninterrupted power supply for fans or coolers (using solar backup), keeping reliable potable water flowing, and arming clinics with cooling kits (ice packs, intravenous fluids, heat stroke treatment kits) to stabilize patients before referral.
In addition, taking an integrated One Health approach, primary care surveillance could be linked with animal health alerts, generated by the Department of Animal Husbandry and Dairying and its state counterparts, since livestock and poultry deaths can be early indicators of extreme heat impacts. Coordinated sharing of such signals can help enable timely joint human-animal healthresponses in rural areas.
2. Redesigning Clinical Care for a Warming World
Heat is rewriting the rules of illness – our clinical playbook must catch up. When temperatures spike, so does the complexity in hospital wards. Heatstroke can present as seizures, dehydration may manifest as low blood pressure, and what appears to be a diabetic collapse may in fact be heat stress[16] . Yet, most existing clinical pathways and protocols do not account for heat stress as a cause. Moreover, chronic conditions like heart disease, diabetes, and kidney disease can be exacerbated by heat[17] , complicating patient management. It is thus critical to strengthen clinical pathways and medical protocols, accounting for the risks that extreme heat poses for such chronic non-communicable diseases. It’s time for an upgrade to the current medical protocols – one that explicitly accounts for heat exposure. Every patient pathway – from the first triage touchpoint to final discharge – must be heat-aware.
In scorching summer months, heat exposure should be a default question on every intake form. Because recognizing heat as a hidden culprit can prevent misdiagnoses and save lives. Especially during heatwaves, emergency rooms must enhance special triage protocols that prioritize patients with heatstroke signs for immediate cooling, allocate extra staff to manage the surge, and possibly set up a dedicated heat corner or heat clinic for rapid response. The protocols used during these heatwaves – for on-site cooling such as evaporative cooling as well as for management of complications (electrolyte imbalances, organ support in severe heat stroke) – must be evidence-based, standardized, and aligned with the national guidelines, such as those issued under the Ministry of Health and Family Welfare[18]. And the care must not end at discharge. Post-recovery follow-ups, for instance by ANM (Auxiliary Nurse Midwives) and ASHA (Accredited Social Health Activists) workers, especially for high-risk populations, should track lingering heat impacts such as kidney stress, confusion, or fatigue and provide tailored advice to reduce the risk of hospital readmission. Such a follow-up could involve a phone call or home visit by a health worker within a week of discharge to check recovery, reinforce preventive advice, and provide guidance on how patients can cool themselves at home.
Finally, every health facility must display in prominent locations the protocols for extreme heat management by citizens and expert medical care providers.
3. Building a Climate-Ready Health Workforce
As heatwaves grow fiercer and more frequent, healthcare workers stand on the frontlines of a crisis they were never trained for. From ASHAs in rural hamlets to specialists in urban hospitals, most have never studied how rising temperatures affect the body, or how to respond when they do. That must change now.
India needs to build a climate-ready, heat-savvy health workforce, and that begins in the classroom and continues in the field. The entire health workforce in India needs new competencies and training to manage heat-induced health risks, which currently remains a peripheral component of healthcare education. This will need updating of medical, nursing, and public health curricula (for ASHA and Anganwadi workers) to include environmental stressors such as climate change (including heat stress) and their impact on human health. It will also need continuous in-service training, e.g., through short certifications, for current health workers (doctors, nurses, ASHAs, paramedics) on identifying and responding to heat-health issues. Innovative training delivery methods – such as digital platforms, simulations and preparedness drills in health facilities before summer, and integration into routine training programs – will be key for achieving high impact at scale.
Community volunteers, high school students, club members, or members of social organizations and youths can be trained to provide preventive as well as immediate lifesaving measures to victims of extreme heat. This can be in line with CPR training provided to youths and students for health emergencies. Readying an alternative human resource like this can ease pressure on overstretched health systems – especially during periods of extreme heat stress.
Information Education and Communication must not end at the health workers, the general public needs to be kept ready too, prominently placing key resources in public areas like ice factories, cool rooms, locations of nearest health facilities etc. for any emergency.
4. Weaving Heat Resilience into the Fabric of Every National Health Program
At present, the National Programme on Climate Change and Human Health (NPCCHH) has set a broad framework for heat adaptation. However, its implementation has been inconsistent across states, departments and health facilities. To be effective, it must be strengthened from within while also ensuring that climate resilience is integrated across mainstream health programs that already reach millions. Doing so will avoid duplication of efforts and ensure an effective and concerted whole-system response.
To achieve this, there is a need to identify strategic integration points within each national program where heat adaptation can be inserted. For example, in maternal health programs, such as Pradhan Mantri Surakshit Matritva Abhiyan, advisories must be added to shield expecting mothers (communities as well as frontline workers) from heat stress, especially in late pregnancy, where extreme heat can trigger preterm labour. Similarly, heat-risk management through counselling and follow-up for chronic, heat-sensitive illnesses could be integrated into noncommunicable diseases programmes such as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), through which patients with diabetes, heart disease, and kidney issues can be counselled on seasonal risks and precautions. At-home caregivers should also be trained to recognize and respond to heat-induced acute events like heart attacks or strokes so they can coordinate with emergency services. Likewise, integration with the National Mental Health Programme could help address the rising tide of heat-linked anxiety, aggression and neurological distress. Nutrition and food security programs as well as Water, Sanitation and Hygiene (WASH) programs could similarly integrate heat adaptation into their folds.
National Programme on Climate Change and Human Health (NPCCHH) can be the umbrella that coordinates these integration efforts across the various verticals. NPCCHH could issue practical directives and checklists for each vertical program, and support states in customizing interventions to local climate vulnerabilities. Where implementation gaps exist, state-level innovation must be encouraged. For instance, some states might integrate heat SMS alerts into their existing health call centers or telemedicine services at the last mile.
5. Building Heat-resilient Health Infrastructure and Governance
Health facilities themselves must be prepared to withstand extreme heat and continue providing care, which requires both physical resilience of infrastructure to cope with heat[19] , as well as strong governance to implement resilience measures. Here lies a golden opportunity: India’s health infrastructure is rapidly expanding, with over 70% of its 2047 goal for health infrastructure yet to be achieved. It is here that resilience must be baked into the blueprints of new infrastructure and climate proofing (e.g. siting, features orientation, insulation, ventilation, energy-efficient cooling systems, and backup power) integrated from the get-go. The Guidelines for Green and Climate Resilient Healthcare Facilities (2023) developed under NPCCHH are a ready playbook for this transition. For instance, such guidelines will ensure that hospital sites are away from flood zones, use thermally efficient building materials (insulated roofs, reflective paint, ample natural ventilation), and integrate renewable energy (solar panels with battery backup for critical equipment). Training architects and contractors on these standards through programs like Kayakalp (hospital quality initiative) could mainstream climate-smart construction for health facilitiesHealth facilities themselves must be prepared to withstand extreme heat and continue providing care, which requires both physical resilience of infrastructure to cope with heat19, as well as strong governance to implement resilience measures. Here lies a golden opportunity: India’s health infrastructure is rapidly expanding, with over 70% of its 2047 goal for health infrastructure yet to be achieved. It is here that resilience must be baked into the blueprints of new infrastructure and climate proofing (e.g. siting, features orientation, insulation, ventilation, energy-efficient cooling systems, and backup power) integrated from the get-go. The Guidelines for Green and Climate Resilient Healthcare Facilities (2023) developed under NPCCHH are a ready playbook for this transition. For instance, such guidelines will ensure that hospital sites are away from flood zones, use thermally efficient building materials (insulated roofs, reflective paint, ample natural ventilation), and integrate renewable energy (solar panels with battery backup for critical equipment). Training architects and contractors on these standards through programs like Kayakalp (hospital quality initiative) could mainstream climate-smart construction for health facilities.
Existing facilities, many of which struggle with power cuts and inadequate cooling, must undergo a mass retrofitting ‘revolution’ to function in hotter conditions. Such targeted retrofitting could be done under the auspice of the Ayushman Bharat Health Infrastructure Mission through which central grants or viability gap funding to states could help install solar-powered coolers or HVAC systems in hospitals of heat-prone districts, establish green corridors around health facilities reducing the urban heat island effect, and improve insulation in maternity wards and ICUs for stable temperatures. For popular public health programmes like immunization, proper infrastructure and services can be designed to support extreme heat resilienceExisting facilities, many of which struggle with power cuts and inadequate cooling, must undergo a mass retrofitting ‘revolution’ to function in hotter conditions. Such targeted retrofitting could be done under the auspice of the Ayushman Bharat Health Infrastructure Mission through which central grants or viability gap funding to states could help install solar-powered coolers or HVAC systems in hospitals of heat-prone districts, establish green corridors around health facilities reducing the urban heat island effect, and improve insulation in maternity wards and ICUs for stable temperatures. For popular public health programmes like immunization, proper infrastructure and services can be designed to support extreme heat resilience.
Heat-resilient infrastructure must go hand in hand with strong governance. That means breaking silos and setting up multi-sector governance mechanisms involving local governments (municipalities, panchayats), health departments and urban planners. For instance, ensuring uninterrupted power and water supply to health facilities during peak summer would need coordination with the power ministry to provide dedicated feeders or backup generators to hospitals, or water authorities to guarantee water tank refills for hospitals during droughts or times of peak usage. Coordination will also be needed vertically – center-state-local levels – to align policies and resources. This requires establishing a cross-sectoral heat health task force that includes officials from urban development, rural development, housing, water resources, agriculture, disaster management and power sectors, at the state and district levels. And in all of these coordination bodies, community and civil society must have a strong voice, as none better can identify vulnerabilities and realities from the ground.
Incorporating health metrics into climate risk monitoring will go a long way in strengthening governance. The Health Ministry should add indicators and metrics, e.g. number of heatstroke cases, facility cooling adequacy, into the National Health Management Information System (HMIS) and periodic surveys. Moreover, health surveillance data should be disaggregated with key metrics such as the primary and secondary cause of death, and reporting systems must be standardized across states, districts, and health facilities; public and private providers; vertical health programmes (maternal and child health, NCDs, mental and occupational health); and interfacing sectors (disaster management, labour, urban development). Such a data-driven approach will enable tracking progress and uncover gaps, ensuring that governance efforts remain outcome-oriented. Monitoring, learning and evaluation remains suboptimal, and digital solutions could play a key role in addressing this gap.
6. Prioritizing Equity in Heat Health Adaptation: Protecting Vulnerable Populations
Extreme heat does not affect everyone equally. The street vendor under the blazing sun, the construction worker laying bricks on a burning rooftop, the farmer tilling parched soil, the urban poor living in dense heat-trapping slums, the elderly, children, and those living with chronic illnesses or disabilities – these are only some of the many at-risk groups that bear the brunt when mercury spikes. Women, including pregnant women, continue to bear a disproportionate burden. Any intervention designed to tackle heat stress must be pro-equity and tailored to the needs of the most vulnerable. That starts with mapping vulnerability in each city and district periodically, understanding where heat hurts the most and who bears the burden. Once we know the “where” and the “who”, targeted solutions – like community cooling centers, shaded public spaces, vertical gardens and early warning systems, must be designed such that they include the needs of the most vulnerable. Such contextualization is critical to the effectiveness of any solution as no single approach works everywhere. For instance, in low-resource settings, only a limited set of active and passive cooling approaches may be feasible. One such passive intervention is cool roof initiatives – applying reflective paint or distributing cheap modular cool roofing material in slums and low-cost housing to reduce indoor temperatures. Cities like Ahmedabad and Hyderabad have successfully piloted cool roof programs. These interventions could be studied and, if effective, replicated more broadly at the national level for all high-heat-risk urban areas, potentially through schemes like the Pradhan Mantri Awas Yojana, Smart Cities Mission, and AMRUT. However, it is important to note that cool roofs can only make a difference up to a point. By reflecting solar radiation, they reduce roof and ceiling surface temperatures, slash air-conditioning demand, and enhance comfort in naturally ventilated spaces – and if adopted widely, they can ease the urban heat island effect. However, overall comfort also depends on convective heat transfer and air movement: heat still enters through walls, floors, and windows, and without adequate ventilation, humidity and poor airflow can limit the impact of cool roofs. Lasting solutions will thus require a more integrated approach with broader passive design strategies and better construction methods that address both radiation and convection, ultimately reducing long-term energy use and building resilience, especially among communities that lack access to air conditioning.
Care must be taken to the vulnerable, where they are, for instance in brick-kilns and old age homes. And in crafting and implementing these on-the-ground solutions, community groups like Self-Employed Women’s Association (SEWA) and other grassroots collectives must play a pivotal role as they have a rich understanding of local vulnerabilities and have piloted innovative coping strategies. Their knowledge is invaluable. Their voices must lead. By embracing participatory planning and feedback loops—where the beneficiaries guide the decisions made for them – sustainability and effectiveness of solutions is ensured.
7. Turning Up the Heat on Investment: Financing Heat Adaptation for a Scalable Future
Implementing interventions for heat adaptation at scale across India will require substantial and sustained funding. And this has historically been an underfunded area. Pilot projects will show what works: community cooling hubs, early warning systems, and climate-ready hospitals. But these life-saving models are often too short-lived, trapped in cycles of limited grants and experimental phases. To truly safeguard public health from heat, innovative financing mechanisms and their integration into mainstream budgets is needed. And for this, climateresilient health initiatives must be made scalable, so they attract diverse investment. That means proving they work – by generating data and evidence on lives saved, illnesses averted, and productivity preserved. With that evidence at hand, the case for long-term funding can be strongly built.
The funding approach must be phased. Instead of treating heat adaptation as a siloed project, it must be embedded within the public budgets. For example, a portion of the National Health Mission or state health budget could fund climate resilience activities (training, retrofitting, outreach), Finance Commission grants could support infrastructure retrofits, or the disaster management funds could pay for preparedness actions like stockpiling heatwave-related supplies. From Smart Cities Mission to Jal Jeevan to Swachh Bharat, funding from existing schemes can be leveraged for heat adaptation. Cross-sectoral heat solutions often map well onto existing programmatic goals of central sector schemes, and this alignment provides a direct pathway to also integrate heat action into urban and rural development programs[20].
This will ensure that funding is predictable, and a business case is built, showing that investments in heat preparedness reduce costs from emergency hospitalizations and productivity losses, strengthening the argument for budgetary support.
On a global scale, India must make a pitch for dedicated climate fundraising from catalytic funds such as the Green Climate Fund, which could help redirect catalytic funds to heat-action, stimulating local innovation and scaling initiatives. Private sector and CSR investment in heat adaptation must be promoted. Companies could be incentivized to financially support local heat action efforts, especially if their operations or supply chains are climate-exposed (aligning with a “polluter pays” or corporate responsibility principle). Public-private partnerships could be explored for technology solutions. For example, telecom companies like Airtel and Jio already send SMS alerts to subscribers on heat, thunderstorm, and flood warnings, albeit with a lag as information flows from the India Meteorological Department (IMD) to NDMA before being issued. These systems must become faster, more localized, and be adopted more widely across telecom providers to ensure timely action at scale. Likewise, a consortium of companies could fund a city’s network of misting cooling centers as a public service. A range of financing mechanisms – spanning public budgets, disaster management funds, and catalytic climate finance – can serve as powerful enablers for scaling public good solutions such as telehealth, early warning systems, and cool roofing. And once such interventions have proven their mettle, they could be swiftly integrated into policy and their scale-up must be fast-tracked. For instance, if a particular state’s experiment with heat-health early warning via a mobile app, enabled by a private provider, shows reduced hospital visits, the NDMA and the Ministry of Health should offer it to all states. Finally, metrics and evaluation for heat adaptation interventions (e.g. heat illness incidence per 1000 population, patient wait times during heatwaves, etc.) must be standardized as these will give the confidence to investors that scaling up will yield tangible benefits.
Conclusion and the Way Forward
A key step towards implementing these recommendations and building a heat-resilient India would need to start with a key bold step: convening a national task force on heat-health resilience that translates these suggestions into an action plan with concrete timelines and responsibilities (perhaps working with the Coalition on Climate and Health). This could build on the existing NPCCHH platform, engaging key ministries and state health departments. A robust monitoring of the plan starting at the district level under the chairmanship of the District Magistrate will provide impetus to the program.
In crafting a heat-resilient health system, India has the opportunity to demonstrate global leadership in climate adaptation. By strengthening its health systems, India will also build its muscle in tackling tomorrow’s climate-induced threats such as floods, vector-borne diseases, zoonotic diseases. And the benefits will only ripple outward: energy-smart hospitals, empowereIn crafting a heat-resilient health system, India has the opportunity to demonstrate global leadership in climate adaptation. By strengthening its health systems, India will also build its muscle in tackling tomorrow’s climate-induced threats such as floods, vector-borne diseases, zoonotic diseases. And the benefits will only ripple outward: energy-smart hospitals, empowered 10 communities, and lives protected. Ultimately, safeguarding health against extreme heat is integral to India’s development trajectory and its commitment to “Health for All”. The time to act is now; with strategic planning and dedicated execution, India can reduce the toll of extreme heat and build a healthier, more heat-resilient future for all her people.
About the Author:
Dr. Pilar Junier is a Swiss-Colombian microbiologist and Full Professor at the University of Neuchâtel, Switzerland, where she leads the Laboratory of Microbiology. With a Ph.D. in Sciences from the University of Chile and a background in genetics from the National University of Colombia, Dr. Junier’s research spans microbial ecology, bacterial-fungal interactions, and environmental microbiology. Originally trained as a bacteriologist, her scientific path took a transformative turn with the discovery of the fungal world, a shift that has profoundly shaped her research and made her a passionate advocate for fungal biology.
Beyond the lab, Dr. Junier is deeply committed to science outreach. She created the award-winning program Microbes go to School, and regularly engages with the public through workshops, school collaborations, and citizen science initiatives. A former President of the Swiss Society for Microbiology and recipient of the Credit Suisse Best Teaching Award, she continues to inspire the next generation of scientists through both her research and her outreach efforts.
References :
- https://doi.org/10.1038/s41467-025-57868-6
- https://doi.org/10.3961/jpmph.18.149
- https://doi.org/10.1016/j.envint.2021.106533
- https://www.who.int/news-room/fact-sheets
- http://lancetcountdown.org/explore-our-data/
- https://apnews.com/article/climate-change-extreme-heat-wave-hot-temperature-a67a14271d1d53021e0cac69da0bc971
- https://doi.org/10.1016/s0140-6736(23)01859-7
- https://doi.org/10.1016/j.eclinm.2024.102865
- https://www.downtoearth.org.in/climate-change/heat-and-humidity-have-started-early-and-intense-courtesy-global-warming
- https://doi.org/10.1016/j.envint.2024.108461
- https://doi.org/10.1016/j.envint.2025.109426
- http://www.imdpune.gov.in/hazardatlas/index.html
- http://www.pib.gov.in/allrelease.aspx
- http://www.sustainablefutures.org/publication/is-india-ready-for-a-warming-world-how-heat-resilience-measures-are-being-implemented-for-11-of-indias-urban-population-in-some-of-its-most-at-risk-cities/
- http://salatainstitute.harvard.edu/india2047/
- https://doi.org/10.1056/nejmra011089
- https://doi.org/10.1016/s0140-6736(21)01208-3
- http://ncdc.mohfw.gov.in/wp-content/uploads/2024/03/Emergency-Cooling-for-Severe-Heat-Related-Illnesses_March2024_NPCCHH.pdf
- https://doi.org/10.1016/s0140-6736(21)01209-5
- http://cprindia.org/workingpapers/finding-the-finance-a-guide-to-identifying-centrally-sponsored-schemes-to-fund-heat-resilience-solutions/