Health Adaptation on Green and

Climate Resilient Healthcare Facilities

 Executive Summary
Climate change and Healthcare
Healthcare services encompassing physicians, nurses, hospital administrators, allied
healthcare professionals, laboratory operations and related services for healthcare delivery
including transport, communications, food services, water and waste management must be
well-prepared and adapted to deliver healthcare services in the event of acute or persisting
impacts of climate change.
As “first responders” to health effects of acute climatic events, healthcare facilities are
expected to be the “last building standing”thereby delivering uninterrupted care.They
neednot only robust infrastructure but also need to become adept to tackle the greater
burden of diseases resulting from the aftermath of floods, droughts, heatwaves, air
pollution, vector-borne disease transmission and post-traumatic disorders, besides
malnutrition.
Often, this is challenged when health care is not adequately prepared. Some examples have
been documented in the recent past of several actors and stakeholders convening together
to handle climate emergencies. Such reactive measures have been successful in care
delivery, but a more planned, structured climate –preparedness and health adaptation
plan will certainly augment and facilitate our work in India and elsewhere to face the
consequences of climate change.
This Centre of Excellence, under the National Program for Climate Change and Human
Health(NPCCHH) is dedicated to developing an implementation framework and action
plan for transformative action in two dimensions of healthcare – resilience and
mitigation (greening), together enshrining the principles of a Climate-Smart health care
system for India.

Defining the concepts of resilience and mitigation

Resilience -Health system resilience can be defined as the capacity of health actors,
institutions, and populations to prepare for and effectively respond to crises; maintain core
functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if
conditions require it.Response to a crisis, be it a disease outbreak or other disruption
resulting in a surge of demand for health care (eg, a natural disaster or a mass casualty
event) needs both a vigorous public health response and a highly proactive and functioning
health-care delivery system.(Ref:Lancet-What is a resilient health system-lessons from
Ebola).A climate resilient healthcare system is one that ensures an adaptive framework
that helps it respond adequately and appropriately in the event of an acute climatic event.
There should be an efficient and trained pool of healthcare and allied professionals
who are able to identify and deal with the additional disease burden associated with
climate change and its impacts on health.
Mitigation – Health care including hospitals, health systems and the health products supply
chain can paradoxically contribute to emissions from the entire lifecycle of their
operations, estimated to be 2.6 gigatons of CO2a year or about 4.6% of total greenhouse
gas emissions. Healthcare systems hence have a responsibility to adopt sustainable,
low-carbon solutions to mitigate and reduce their own climate footprint.

Together, resilience and mitigation, with often an overlap in measures taken, combine
to build a Climate-smart health system that can adapt to deliver critical healthcare
services in the face of climate change.

This encompasses good location of the healthcare facility, appropriate building standards,
efficient access and utilization of energy, water, food, transport, communications as well as
correct waste management practices. A critical link to such an adaptation plan will include
access to climate information services that provide weather forecasting, vulnerability
assessments, risk predictions, and disease surveillance systems that can ensure an adequate,
integrated and coherent response.

Challenges and Opportunities

Indian Healthcare System: The Indian healthcare system is a diverse, multi-tiered one with
several players and governance structures. An implementation framework for climate
preparedness and action will therefore vary with the tier of the system and the various actors
and stakeholders involved.Of note, the concepts of green and climate resilient healthcare
have been incorporated within the Indian Pubic Health Standards and can soon be
established as the norm for the public health care system.
The concept has also been recognized and adopted by leading heads and administrators of
private healthcare facilities and organisations representing healthcare professionals in India.
This can be leveraged to bring in the framework in practice through these networks.
The Centre of Excellence for Green and Climate Resilient Healthcare facilities is
located at the Centre for Environmental Health at the Public Health Foundation of
India. The technical support team here will be available to handhold state nodal
officers through the steps to establish climate resilient and green healthcare facilities
at every level of the health system with coordinated action through the National
Centre for Disease Control and other Centers of Excellence in the National Action
Planfor Climate Change and Human Health (NAPCCHH)
 FRAMEWORK FOR CLIMATE RESILENCE AND MITIGATION

An overarching framework will be provided that covers action, timing and resources (human
resources and tools involved) for a healthcare facility to be resilient and green. Actual ground
implementation in the states will then be customized and prepared for every level of health
care in the state plans, in co-ordination with the State Nodal Officers.

FRAMEWORK FOR CLIMATE- SMART HEALTH SYSTEMS

Core domains for action for Implementation of Climate-smart healthcare

I. Health professionals’capacity-building – Climate preparedness and
adaptation

i.The impacts of climate change on human health range from acute respiratory
illnesses due to poor air quality, increase in incidence and exacerbation of current
cardio-respiratory conditions due to air pollution and worsening
heatwave/coldwave conditions, increase in water-borne and vector-borne
diseases, worsening of nutrition-related disorders and an alarming increase in
mental health disorders.
 Every region/state may have different vulnerabilities and this disease vulnerability
assessment will form the fundamental block of health sector preparedness of each
region.

ii. Health and allied professionals must be adequately sensitized to recognize this growing
disease burden and be well-trained to provide both preventive and curative care to their
patients and communities. Capacity –building of the healthcare professionals lies at
the core of climate preparedness and can be achieved through a structured training
program through virtual or in-personteaching modules.

iii. A list of resources can be built that include freely available virtual trainings by WHO
and other organisations, with self-paced training on climate change and health impacts.
Additionally, virtual or in-person trainings can be organized through the NAPCCHH for
State Nodal Officers, district medical officers, and health professionals in allied disciplines
like nursing, pharmacy, laboratory services, health administration and public health
specialists at state and district level.

iv. Information-education-communication (IEC) materials on climate change and

human health impacts in English and local languages can be widely disseminated and
displayed at strategic locations in healthcare facilities and communities. Short videos and
educational material can be made available to enhance awareness through television or
print media.

v. Finally, a mobile-based app linked to tele-medicine services must be made

available for use in the event of acute climatic events.

vi. Training in climate change and health impacts must become an integral part of
medical and allied professionals’ curriculum. This policy change must be collectively
driven by NAPCCHH and allied national programs related to environmental pollution.

II. Health infrastructure strengthening for resilience and mitigation

Indian Healthcare System: The Indian healthcare system is a diverse, multi-tiered one with
several players and governance structures. An implementation framework for climate
preparedness and action will therefore vary with the tier of the system and the various actors
and stakeholders involved.
Figure 1: India’s healthcare system is characterised by multiple systems of medicine, mixed ownership
patterns and different kinds of delivery structures
 The resilience of healthcare facilities includes both retro-fitting existing facilities
andincorporating principles of resilience and “greening” in new establishments.
An important component will be an immediate focus on the refurbishing of 1,50,000 Sub-
centers and primary health centers as Health and Wellness centers in the Ayushman
Bharat programaiming at Universal health coverage through Comprehensive Primary
Health Care(CPHC). Wider health system strengthening through co-ordinated action via
both National and State Health Systems Resource Centre and established private
hospital networks can move the Indian healthcare system on a steady path towards
decarbonisation and climate –smart healthcare.
FRAMEWORK FOR HEALTH FACILITY INFRASTRUCTURE RESILENCE AND
MITIGATION
I. SITE SELECTION
ACTION
A pre-site assessment or a climate vulnerability assessment for the siting of healthcare
facility needs to be conducted to explore current and future climate risks associated with the
facility.
RESOURCE
Vulnerability assessments(VA) can be conducted using the tool developed by the Centre of
Excellence for vulnerability assessments under NAPCCHH.
IMPLEMENTATION
Based on the assessment, the relevant Centre for Excellence needs to be consulted for pro-
active action. For instance, if the facility is vulnerable to vector-borne diseases or heat
related issues, the related experts or the health adaptation plan for those climate risks needs
to be followed. If the facility is situated in a flood or drought prone area, relevant risk
protocols and plans should be in place to mitigate impacts of these extreme events.
i. Based on VA, appropriate siting of the health care facility must be planned for
new facilities. For existing facilities, protective measures must be implemented
based on the VA to protect the facility from impacts of acute climatic events.
ii. Emergency or disaster preparedness at health facility level must be
contextualized based on previous patterns of climate events in the region.

iii.

II. Building design for healthcare facility(HCF)

The healthcare facility building itself must bemodeled after assessing vulnerabilities the
state has from climate change impacts. The building design must include sturdy and
sustainable building materials that while being able to withstand acute climate events like
floods, heatwaves and poor air quality are also environmentally sustainable and essentially
help in reducing the carbon footprint of the facility.
ACTION
The infrastructural assessments include an assessment of the building materials, climatic
durability of the hospital structure, efficient lighting and ventilation and an adequate focus on
development of greenery within and surrounding the facility. A pre-site assessment or a
climate vulnerability assessment for the building structure and design needs to be conducted
to explore current and future climate risks associated with the facility.
RESOURCE
Vulnerability assessments can be conducted by the public health engineers in public health
facilities and administrators in private hospitals using standard resources including Green
Rating for Integrated Habitat Assessment (GRIHA),Indian Green Building Council(IGBC),
Green hospital standards and Retrofit guidelines for existing facilities.(Annexures)
IMPLEMENTATION
Based on the assessment, the appropriate infrastructural changes can be implemented
keeping in mind timing. Some of the changes that may be proposed include:
i. Prepare for installation of cool roofs well ahead of the anticipated heat wave
season
ii. Ensure flood marks are adhered to and access and exit points are assessed
iii. Propose refurbishing of the building beginning with critical service areas such as
the emergency room, labor rooms, intensive careareas, operation theatres,
essential services like laundry, catering or operational facilities controlling water,
and power supply, laboratory facilities and in-patient areas.
A draft action plan for stage-wise refurbishing without severe disruption to service
delivery must be prepared and implemented within reasonable timelines.

III. Energy management in the healthcare facility(HCF)

The energy utilization pattern of the healthcare facility must be assessed at the baseline to
understand the demand across the facility, energy load and supply matrix, source of energy
supply, patterns of disruption in the past and a critical services prioritization list must be
developed.
ACTION
i. A baseline assessment of the energy utilization of the healthcare facility for maintainence
of heating, lighting, operation of equipment, essential services like water in all areas,
functional services in critical areas like the labour room, operation theatres, intensive care
units besides the overall facility must be mapped out.
ii. An audit of the energy sources of the entire facility, grid mix, existing use of alternate
sources of energy like renewable energy must be conducted.
iii.A risk mapping of the energy demand and supply outlining patterns of disruption in the
past should be conducted.
iv.A clear analyses of the patient footfall through the year, linked to factors like seasonal
disease burden, climatic information services with forecasts, for example, of floods or
heatwaves and peripheral services dependent on energy supply like outreach clinics and
immunization drives requiring efficient functioning of vaccine supply cold chain must be
completed.
v.For both retrofitting existing buildings and in new health facilities, a framework for
establishing a team of energy managers trained to work in tandem with public health officers,
hospital administrators, public health engineers and operations and maintainence personnel
for ensuring a continuous supply of energy to maintain functional services at all times.
RESOURCE
Baseline energy audits can be conducted using our energy and health audit checklist by the
team of energy manager,public health officer and hospital administrators.
IMPLEMENTATION
Based on the assessment, the appropriate infrastructural changes can be implemented
keeping in mind timing. Some of the changes that may be proposed include:
i. Develop a plan for provision of clean and efficient energy supply from
appropriate sources –grid and renewable energy based on the facility
requirement
ii. Ensure 24/7 supply for critical areas with a thermostat or other
mechanism to switch off lights and other appliances where not in use.
iii. Installation of LED lighting in all areas with adequate attention during new
constructions to maximize natural lighting and ventilation.
iv. Replacement of diesel gensets with solar or wind powered alternatives.
v. Inclusion of energy efficiency as a criterion in procurement of medical
equipment.
A draft action plan for stage-wise refurbishing without severe disruption to service
delivery must be prepared and implemented within reasonable timelines.
 IV. Water management in the healthcare facility

An assessment of the water demand, utilization across different sections of the

facility and the supply matrix must be assessed at the baseline. A critical facilities
prioritization list for water supply must be prepared.

ACTION
i. A baseline assessment of the water utilization of the healthcare facility for maintainence of
essential functional services in critical areas like the labour room, operation theatres,
intensive care units besides the overall facility must be mapped out.
ii. An audit of the water sources of the entire facility must be conduct by the public health
engineers and hospital administrators, options available for additional supply and
conservation strategies including rainwater harvesting measures must be assessed.
iii. A risk mapping of the water demand and supply outlining patterns of disruption in the past
should be conducted.
iv.A thorough assessment of wastewater management is also mandated with documentation
of successful existing measures and options for new strategies for wastewater treatment,
recycling and disposal.
RESOURCE
Baseline water management audits can be conducted using our green hospital standards
and and master checklist for environment-friendly sustainable health facilities.
IMPLEMENTATION
Based on the assessment, the appropriate infrastructural changes can be implemented
keeping in mind timing. Some of the changes that may be proposed include:
i. Develop a plan for provision of clean and efficient water supply from appropriate
sources based on the facility requirement
ii. Ensure 24/7 supply for critical areas with a plan for storage of water for functional
healthcare delivery during critical periods.
iii. Installation of rainwater harvesting infrastructure with a system for quick transition to
this source when appropriate.
iv. Establishment of waste water treatment and recycling facility with a mapped facility
plan for reuse in the toilets, garden, etc
v. Regular monitoring of all plumbing fixtures to manage leaks etc and securing of
overhead tanks and other water storage facilities
vi. Adequate planning with water board engineers for storm water management and
facility-level management of stagnant water
A draft action plan for stage-wise refurbishing without severe disruption to service delivery
must be prepared and implemented within reasonable timelines.

V. Waste management in the healthcare facility

A thorough baseline assessment of management of general(solid) waste, biomedical waste,

food waste, plastic waste, e-waste and end-of-cycle management of equipment, including
medical devices must be conducted.
ACTION
i. A baseline assessment of the waste generation and management strategy for all
categories of waste must be conducted by a waste management team.
ii. An audit of the quantum of waste, segregation at source, storage and disposal channels
must be mapped with identification of gaps throughout the lifecycle of waste management.
iii. A risk mapping of the biomedical waste management practices accounting for health
worker and waste handler safety must be conducted.
iv. A thorough assessment of established channels for efficient waste disposal and linking
with new resources where required should be completed.
RESOURCE
Baseline waste management audits can be conducted using our green hospital standards
and and master checklist for environment-friendly sustainable health facilities.

IMPLEMENTATION

Based on the assessment, the appropriate infrastructural and functional changes can be
implemented keeping in mind timing. Some of the changes that may be proposed include:

i. Develop an operational plan for all categories of waste management

under the health facility waste manager and team, with compliance to
existing rules and policies
ii. Ensure channels of waste disposal even during critical periods when
functional capacities exceed normal demand.
iii. Ensure protection of healthcare workers and waste handlers at all levels.
iv. Regular monitoring and evaluation of waste handling steps for all
categories of with course correction where appropriate.
v. Options for waste recycling, composting of dry and wet waste and reuse
within the health facility must be explored.

A draft action plan for stage-wise refurbishing of waste management systems with adequate
reinforcement of management methods through training and provision of operation manuals
and resources must be prepared and implemented within reasonable timelines.

VI. Sustainable procurement for healthcare

The incorporation of sustainable procurement practices and solutions in health

care service delivery and manufacture and purchase of goods , including medical
equipment, pharmaceuticals and overall supplies forms a critical component of
green and environmentally-friendly health care facilities.
 ACTION

i. The establishment of a sustainability or green committee within the healthcare facility

can help to incorporate the practices of sustainable healthcare delivery and transition to
sustainable alternatives for procurement of goods and services
ii. Creating a demand for sustainable alternatives must become a practice and could range
from incorporating energy efficiency criteria in technical specifications for procurement
of medical equipment to transition to non-PVC gloves.
iii. Awareness building and provision of sustainable alternatives within procurement portals
of general procurement must be promoted.

RESOURCE

A sustainable procurement in healthcare guide is available to guide the transition to

sustainable practices. Wide dissemination and training is critical to facilitate adoption of
these strategies.

IMPLEMENTATION

i. A baseline assessment of potential opportunities for replacement of some

categories of products and services with sustainable alternatives can be
conducted.
ii. The sustainability committee can engage with manufacturers and suppliers to
stimulate production of sustainable alternatives by creating demand from health
facilities for “green’ products.
iii. The committee can assess the high impact products and prioritise these
categories in routine procurement. Examples include high-volume products such
as PVC gloves and disinfectants which have both environmental and health
impacts.

A sustainability action plan for the healthcare facility can be developed with scope for iterations
and timeline for implementation as new sustainable solutions become available.

VIII Sustainable Transport and Communications

An optimal system for transport services for patients, healthcare providers and healthcare service
delivery encompasses transport services across the lifecycle of health care delivery. This includes
supply chain for delivery of goods, transport of patients and providers, service delivery including last
mile delivery in rural and remote areas as well as end-of-cycle disposal of goods. Communications
include linkages to disease surveillance systems and warning systems for disaster preparedness and
response.

ACTION
 i. Mapping of the transport requirements for all components of healthcare delivery
can help to prioritise development of a framework for an efficient transport system
to ensure functional and sustainable services at all times and particularly during
crises.
ii. Assessment of the requirement for community outreach for healthcare services
including home visits for antenatal care, immunization etc including frequency
and distance must be conducted
iii. An evaluation of access to sustainable travel options for patients and providers
through provision of access to public transport services, pooled services where
appropriate and emergency access to transport for remotely located patient
populations must be conducted.
iv. A baseline evaluation of the communication channels for internal functioning and
linkages to essential services must be conducted to assess the gaps in delivery
v. A robust system of linkages to disease surveillance, disaster response and
emergency preparedness must be established.
vi. A scoping of the communication services for provision of telehealth services and
incorporation of digital health strategies for efficient healthcare delivery,
especially last-mile connectivity, must be carried out with external consultants
where appropriate.

RESOURCE – A guide and manual of operations for Hospital Climate Action Plan will
be made available. This must be contextualized to the particular facility and linked to
disaster response measures as outlined for overall emergency preparedness.
IMPLEMENTATION
i. Establishment of pooled transport service strategies for patients and providers
ii. Facilitation of sustainable supply chain choices for goods and services through
linking public and private transport operations
iii. Establishment of functional communication channels for delivery of essential
services
iv. Promoting incorporation of telehealth services to close the gaps in access to health
care services
IX Climate Information services
The health facility must be linked to efficient climate information services that provide
forecasting and warnings of acute changes in weather conditions and onset of acute
climatic events like storms, floods, heatwaves, coldwaves and drought conditions.
ACTION
i. Establish linkages to meteorological services for timely climate information to the
healthcare facilities
ii. Establish a plan for emergency response with regular mock drills organized by
designated administrative personnel
iii. Develop and prepare an emergency hospital action plan for movement and
evacuation of patients, personnel and facility assets in the event of an acute
event with functional services for acute illness and injury management
RESOURCE
Websites of state meteorological services and Ministry of Earth Sciences
 IMPLEMENTATION
i. The healthcare facility communication system must be linked to the state
meteorological websites and helplines for receiving timely information and
forecasting messages and alerts.
ii. A disaster response team must be constituted under the control of the hospital
administrator and public health officer for coordinated action when required.
iii. Regular mock drills must be conducted after allocation of roles and
responsibilities across different hospital personnel involved with both patient care
and support services.
iv. A plan for establishment of temporary or mobile shelters must be in place.
v. Evacuation plans and provision for skeletal functioning of essential services in the
event of an acute event must be established.

X. Capacity building and Leadership

The entire organizational structure for efficient and coordinated climate response requires
capacity building at all levels. The State Nodal Agency and the State Nodal Officer for
Climate Change and his/her team must be equipped and aware of the requisite skillsets for
climate adaptation of the healthcare facilities.
ACTION
i. Awareness and sensitization of healthcare professionals and facility staff regarding
acute climate events and related disease burden
ii. Skill-building programs for all personnel involved in different components of health
care delivery from patient care to allied and support services
RESOURCE
Training modules and training of the trainers courses will be available for capacity-building at
state and district level.
IMPLEMENTATION
i. Established short –term trainings for State Nodal Officers and health facility
–level officers in public health and public works department to ensure
essential services in a coordinated manner
ii. Specific courses for waste management, sustainable procurement etc for
designated officials involved in the management of these verticals.

CONCLUSION
Overall an action plan with efficient inter-sectoral coordination and capacity-building at all
levels will be necessary to help the healthcare facilities in the public and private systems to
prepare for climate change. This health adaptation plan is proposed as a guide for action in
all states and can be further contextualized for state and facility-level action.

ANNEXURES
i. All listed resource documents
ii. Master checklist for implementation framework of WHO for green and
climate-resilient healthcare facilities
iii. Master checklist for implementation framework of CoE for green and
climate resilient healthcare facilities.