Climatic Change (2023) 176:154

https://doi.org/10.1007/s10584-023-03630-0

Climate change and human health: estimating district‑level

health vulnerabilities in the Indian context

Divya Chaudhry1 · Indranil Mukhopadhyay1

Received: 16 March 2023 / Accepted: 21 October 2023

© The Author(s), under exclusive licence to Springer Nature B.V. 2023

Abstract
Evidence of the health impact of climate change has been extensively documented in
recent scholarly literature. In order to mitigate the adverse health effects induced by climate
change, the need for conducting vulnerability assessments (VAs) has been emphasised. A
higher vulnerability to climate change is often linked with substantial risks to human lives
and built environment. Despite the potential of VAs in alleviating risks posed by climate
change, only a limited amount of scholarly work in this domain has been conducted in the
Indian context. The present research addresses this lacuna and contributes to the limited
scholarship on climate change and health VAs in India. Drawing on the VA framework
introduced by the fourth assessment report (AR4) of the Intergovernmental Panel on Cli-
mate Change (IPCC), this paper estimates district-level health vulnerabilities caused by
climate change using multi-dimensional indices. The indices are multi-dimensional since
they integrate 50 district-level indicators from 8 data sources for all 640 Census 2011 dis-
tricts. The statistical technique of Principal Component Analysis (PCA) has been used for
integrating the indicators. The findings of this paper indicate that nearly 56% of India’s
population in 344 districts is highly vulnerable to the health impact of climate change. The
results show that high vulnerability in certain districts is mediated by high adaptive capac-
ity (AC). Since climate exposure varies across districts, the paper highlights the need for
local-level responses and Complex Adaptive System (CAS) thinking to understand the
implications of climate change and human health.

Keywords Human health · Vulnerability · Climate change · Vulnerability assessments ·

Districts · Complex Adaptive Systems

1 Introduction

Efforts to estimate health vulnerabilities induced by climate change have gained impe-
tus since the late 2000s. According to the fourth assessment report (AR4) of the Inter-
governmental Panel on Climate Change (IPCC), climate change vulnerability depends on

* Divya Chaudhry
dchaudhry@jgu.edu.in
1
Jindal School of Government and Public Policy, O.P. Jindal Global University, Sonipat,
Haryana 131001, India

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the exposure of a system to the nature, intensity, and pace of climate change and extreme
weather events, in addition to the sensitivity and adaptive capacity (AC) of that system
(IPCC 2007). Sensitivity refers to the extent to which a system or species is impacted by
climate change whereas AC refers to the potential of a system to bear the impact of cli-
mate-induced extremes and recuperate from the ensuing damages.
The vulnerability framework may be applied to understand human health vulnerability
as a result of exposure to climate-induced extremes and disasters. Health vulnerability is
often regarded as a combination of ‘risk and protective factors’, which help in ascertain-
ing an individual’s or society’s predisposition to unfavourable health effects from being
exposed to extreme weather events (Balbus and Malina 2009). Given an equivalent level
of exposure, human health vulnerability to climate extremes is strongly governed by fac-
tors such as access to safe drinking water, sanitation, healthcare facilities, socioeconomic
status, demographics, and health status of populations. It is reasonable to infer that factors
which influence health vulnerability are intrinsically linked with the social determinants of
health (SDH) (Balbus and Malina 2009; Buse and Patrick 2020).
Even though climate change is a global phenomenon and is expected to exacerbate
global health risks, the extent of risk varies across geographies and also across population
groups within the same geography. Furthermore, as different geographies are susceptible
to varied climate and weather conditions that may make them prone to wide-ranging risk
factors, large-scale vulnerability assessment (VAs) may overlook such spatial diversities,
which may render such assessments futile (Yu et al. 2021). Therefore, recent VA frame-
works have focussed on obtaining meteorological information as well as evidence on risk
factors and health outcomes for smaller subnational geographic units such as census tracts
and districts.1
A number of studies have estimated health vulnerability to climate change for smaller
geographies in the international context. It is worthwhile to briefly discuss some of them.
Menezes et al. (2018) designed a municipal vulnerability index for 62 municipalities in the
state of Amazonas in Brazil by aggregating indicators representing environmental, socio-
political, socioeconomic, demographic, local governance, and social capital. Prudent et al.
(2016) measured health vulnerability to floods and heat-related hazards in Travis County,
Texas. Yu et al. (2021) estimated health vulnerability to extreme heat, flooding, wildfire
smoke, and ground level ozone in the Canadian province of British Columbia for 4188
Census dissemination areas. Bae et al. (2019) computed the impact of increased ozone con-
centrations as a result of climate change on human health for 249 jurisdictions in South
Korea. The literature on VAs is particularly extensive for high-income countries and is
based either on a full spectrum of climate hazards and health impacts or on specific climate
hazards and health impacts (Pradyumna and Sankam 2022).
In India, only a limited number of assessments have been undertaken to evaluate human
health vulnerability to climate change. Following the VA framework introduced by AR4,
Dogra et al. (2019) developed a health vulnerability index for 15 flood-prone districts in
Bihar. The authors assumed a constant level of exposure across all districts. Second, a heat
vulnerability mapping was done by Azhar et al. (2017) for all 640 districts in India using a
similar VA framework. The authors considered two population health indicators (immuni-
zation of children under 2 years and distance from sub-centres) in their study. Third, Sehgal

1
Frameworks like Building Resilience Against Climate Effects (BRACE) have emphasised the need for
developing vulnerability assessments in view of local climate, health outcomes, and risk factors for the
‘smallest possible administrative unit’ (Manangan et al. 2015, p. 1).

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Climatic Change (2023) 176:154 Page 3 of 20 154

et al. (2021) used a study on district-level agricultural vulnerability to climate change as

the basis for calculating child health vulnerability to climate-induced agricultural risks.
Fourth, Gupta et al. (2021) and Mahapatra et al. (2023) have empirically established link-
ages between climate change and risks to maternal and child health at the district-level.
Given the existing evidence of health vulnerability induced by climate change, it is rea-
sonable to infer that with respect to the Indian context, this evidence is far from adequate.
This is not only due to the miniscule number of such studies, but also because the scope of
the existing studies is narrow in terms of their focus on meteorological, human health, and
socioeconomic profiles of districts. We attempt to address this lacuna and contribute to the
existing scholarship on health VAs in India. We do this by creating multi-dimensional indi-
ces that comprehensively characterise vital aspects of exposure, sensitivity, and AC.
We draw on the VA framework of the IPCC to estimate health vulnerability to climate
change. Since VAs conducted at smaller administrative units capture health vulnerability to
climate change more accurately, we carry out our analysis for all 640 Census 2011 districts
of India. We make use of 50 indicators from 8 data sources — 14 for exposure, 20 for sen-
sitivity, and 16 for AC — and construct separate indices for each of the three vulnerability
components. Whilst exposure and sensitivity positively influence vulnerability and depict
the potential impact of a climate change-induced event, AC plays a role in alleviating the
impact and reducing vulnerability. We opt for the AR4 conceptualization over the recon-
ceptualised vulnerability notion introduced in AR5 and adopted in AR6 because the new
conceptualization separates vulnerability from exposure. We provide a detailed explanation
in Electronic Supplementary Material 1 (ESM 1).
Our paper contributes to the narrow body of literature on health VAs in the Indian con-
text. It builds upon the VA framework proposed by the IPCC (AR4), which resonates with
SDH. The final vulnerability results are based on three independently created indices, each
of which represents a distinct dimension of vulnerability. Our paper is unique in at least
two ways. First, the indices are constructed by using a multitude of indicators from 8 data
sources, all of which influence human health vulnerability to climate change. Second, the
scope of this study extends to all 640 Census 2011 districts.
The remainder of the paper is structured as follows. Section 2 details the data used in
each component of vulnerability. The rationale behind including 18 CSDs and VBDs, and
the estimation process of indicators included in the analysis has also been discussed. Sec-
tion 3 discusses the methods used in the paper. Section 4 presents the results pertaining
to each index and robustness checks to ensure the validity of results. Section 5 probes the
results, provides policy implications, and highlights the limitations of the study. Section 6
consists of concluding observations.

2 Data estimation and sources

The findings of this study are based on data from 8 sources. All the datasets are freely and
publicly available. We discuss the sources and estimation process under each vulnerability
component. Data estimation and collation have been conducted on STATA 17.0. The initial
dataset comprised more than 80 indicators. Indicators that depicted similar constructs were
omitted before data processing.
Selection of indicators is determined by a thorough review of literature. Each vul-
nerability component is further decomposed into several sub-components. Exposure
is composed of indicators depicting meteorological phenomena, built-up population,

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disastrous weather events, and air pollution. Sensitivity includes indicators representa-
tive of child health status and the prevalence of chronic diseases, hospitalization rate
due to all causes and 18 climate-sensitive diseases (CSDs) and vector-borne diseases
(VBDs), household healthcare expenditure attributable to all diseases and 18 CSDs
and VBDs, socioeconomic, and demographic characteristics. AC consists of indicators
explaining household and socioeconomic characteristics, health system performance,
healthcare infrastructure, and vegetation.
Tables S1, S2, and S3 of ESM 1 present an overview of indicators used for esti-
mating exposure, sensitivity, and AC indices, respectively. Relevant citations that sub-
stantiate the inclusion of these indicators either empirically or theoretically are also
provided in these tables.

2.1 Indicators used for estimating exposure index

Data for all meteorological indicators have been sourced from the geospatial covari-
ates’ dataset appended to the fourth round of National Family Health Survey (NFHS-4)
on the Demographic and Health Surveys (DHS) Program website. This dataset pro-
vides meteorological data for 28,526 DHS clusters, which are household groups that
agreed to take part in the survey (The DHS Program 2015–2016). We combined this
data with the individual recode data of NFHS-4 to arrive at district-wise data for mete-
orological indicators. In order to consider the extent of climate change, we take the
absolute difference of all temperature-related, rainfall, precipitation, aridity, and poten-
tial evapotranspiration (PET) indicators between two time points — 2005 and 2015.
We take 4 temperature-related indicators to depict climate change-induced impact
on both air and land surface temperatures. Climate change is associated with a rise
in both maximum and minimum temperatures. We use day land surface temperature
(DLST) and night land surface temperature (NLST) to account for increase in surface
temperatures. We include a measure on population for the year 2014 to capture the
extent of urbanization and density of built-up structures in districts. Since climate
change is expected to increase the frequency, intensity, and duration of extreme pre-
cipitation events, we take data on precipitation, rainfall, and aridity to account for pre-
cipitation extremes. In the absence of actual evapotranspiration data, we take data on
PET. We justify the inclusion of these indicators in ESM 1.
To account for the disastrous nature of climate extremes, we include data on heat
wave days, cold wave days, and flood events. Note that these are disastrous weather
events (DWEs), in that each episode of DWE led to at least one human death. These
are cumulative DWEs that occurred between 1969 and 2019. As many DWEs like
thunderstorms and cyclones are characterised by extreme wind speeds, we take data
on extreme annual wind speeds (in meter per second with 50-year return period). We
include data on DWEs for the three extreme categories according to the classification
provided by the Indian Meteorological Department (IMD 2022). We provide an expla-
nation for this in ESM 1.
Climate and air quality mutually influence each other. We have elaborated on the
pathways in ESM 1. We take fine particulate matter (PM2.5) data as proxy for ambient
air pollutants. We have sourced district-level PM2.5 data from the Centre for Atmos-
pheric Sciences, Indian Institute of Technology (IIT), Delhi.

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Climatic Change (2023) 176:154 Page 5 of 20 154

2.2 Indicators used for estimating sensitivity index

Evidence demonstrating the impact of climate change on human health is plentiful.

The type of weather events and potential health outcomes associated with each weather
event have been tabulated in Table S4 of ESM 1. The existing evidence aided the iden-
tification of 18 CSDs and VBDs from the 75th round of the NSS (Ministry of Statistics
and Programme Implementation 2019b) (Table S5). This was done after carefully estab-
lishing a correspondence between the list of ailments listed in NSS, the Tenth Revision
of International Classification of Diseases (ICD-10), and the International Classification
of Primary Care (ICPC-3).
The rationale behind mentioning VBDs separately has been discussed in ESM 1. The
process involved in the estimation of out-of-pocket (OOP) health expenditures, cata-
strophic health expenditures (CHE), hospitalization rates, and population below poverty
line (BPL) has been elaborated in ESM 1.

2.2.1 Socioeconomic and demographic characteristics

In order to precisely capture socioeconomic and demographic characteristics in our sen-

sitivity index, we estimate the fraction of population aged 60 years and above, and the
share of population belonging to disadvantaged social groups, viz. Scheduled Castes,
Scheduled Tribes, and Other Backward Classes, from NSS. From the Periodic Labour
Force Survey (PLFS), we estimate the share of unemployed population, i.e. persons
belonging to a working age population who sought work or are available for work but
are unable to find work, and the population working in vulnerable jobs. In our analysis,
we consider jobs to be vulnerable when workers are working on temporary job con-
tracts, bereft of a social security allowance (provident fund in our case), and ineligible
for paid leave (Ministry of Statistics and Programme Implementation 2019a).

2.2.2 Infant mortality rate (IMR)

We include district-wise infant mortality rate (IMR) from Dandona et al. (2020) and
indicators depicting the health status of children in the calculation of our sensitivity
index (International Institute of Population Sciences (IIPS) and ICF 2017). Child health
status indicators measure the prevalence of diarrhoea, acute respiratory infection (ARI),
stunting, wasting, underweight, and anaemia in children (ESM 1). This is because cli-
mate change may exacerbate the health of children in districts which fare poorly in vital
child health indicators.

2.3 Indicators used for estimating AC index

In calculation of AC index, we include indicators which can assuage the impact of cli-
mate change on human health. We take indicators representing background character-
istics of households, viz. access to electricity, improved source of drinking water and
sanitation, clean cooking fuel, and health insurance (IIPS and ICF 2017). Since sound
healthcare infrastructure and adequate human resources for health are crucial to mitigat-
ing the adverse health consequences of climate change and DWEs, we have included
indicators depicting healthcare infrastructure and health system performance. We take

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the sum of sub-centres and health and wellness centres (henceforth, ‘health facilities’)
for all districts from Rural Health Statistics, 2018–2019 (Ministry of Health and Family
Welfare 2019). We estimate Census-adjusted NSS population2 and calculate the number
of health facilities per capita. We compute a measure of within-district hospitalizations
from NSS as proxy for health systems’ capacity of districts in terms of delivering IPD
treatment. We estimate five indicators from NFHS-4 (IIPS and ICF 2017) to characterise
the health system performances of districts. These are proxies for skilled health person-
nel (births attended by skilled health personnel), children’s health, nutrition, treatment
of childhood diseases, and capacity of healthcare facilities in treatment and diagnosis of
communicable (tuberculosis), childhood diseases (diarrhoea), and non-communicable
diseases (hypertension). Since vegetation cover is associated with a positive impact on
mitigation, such as preventing droughts and inhibiting rainfall and storms from causing
runoffs, we include a measure of enhanced vegetation index (EVI) in our AC index (The
DHS Program 2015–2016).3 Last, we estimate and incorporate indicators that influence
socioeconomic conditions positively in our AC index, viz. share of literate population
and labour force from PLFS and mean monthly per capita consumption expenditure
(MPCE) from NSS. The method for estimating MPCE has been detailed in ESM 1.
Note that exposure and sensitivity indicators have a positive relationship with vulner-
ability whilst AC indicators have a negative relationship with vulnerability. The classifica-
tion of socioeconomic characteristics under sensitivity and AC was carried out keeping this
relationship in mind. This is crucial from the perspective of applying PCA. PCA works best
when indicators under each component have a consistent relationship with the construct.

2.4 Vulnerability index

We compute the vulnerability index by adding exposure and sensitivity index values and
subtracting AC index values from this sum (Maiti et al. 2015; Monterroso et al. 2014). The
concept of vulnerability has been diagrammatically represented in Figure S1 of ESM 1. We
normalise these values using (i) to facilitate interpretation.

3 Methods

We use PCA to calculate indices measuring exposure, sensitivity, and AC for all 640 dis-
tricts. STATA 17.0 has been used to apply PCA to the dataset. PCA is a widely used statistical
technique for dimensionality reduction in that a smaller number of uncorrelated factors are
extracted to account for the maximum variance in data. The first factor extracted through PCA
explains the maximum variance of original indicators whilst each subsequent factor explains
the remainder variance. PCA is particularly preferred over other statistical techniques as it
enables exploratory analysis of data and does not require a prior understanding of how vari-
ables are related to each other (Mooi et al. 2018). PCA prevents loss of variance and facilitates
creation of new factors based on the original dataset (Jolliffe and Cadima 2016).

2
Population size in NSS is underestimated. To scale-up the NSS-estimated population size for Indian dis-
tricts, we derive a multiplier by calculating the ratio of Census projected total population size for 2018 and
NSS population. Product of district-wise NSS population and the multiplier in considered in our analysis.
3
EVI is based on high-resolution data which enables it to minimise inaccuracies arising due to haze,
clouds, aerosols, and land underneath the vegetation.

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Climatic Change (2023) 176:154 Page 7 of 20 154

PCA was considered statistically appropriate to aggregate indicators for all sub-indices
in our analysis. First, the number of districts, which are observations in the current analysis,
are more than 10 times the number of variables under exposure, sensitivity, and AC. Since
PCA works well with large datasets, this rule of thumb ensures that maximum variance of
original datasets is retained by the new factors (Jolliffe and Cadima 2016; Mooi et al. 2018).
Second, the Kaiser–Meyer–Olkin (KMO) statistic has been used to test the strength of correla-
tion between variables. The aggregate KMO measure for standardised exposure, sensitivity,
and AC is 0.676, 0.702, and 0.730, respectively. In fact, all variable-specific KMO values are
above 0.4, which is an acceptable threshold to test sufficiency of correlation between variables
(Shearer et al. 2021) (ESM 2). Third, Bartlett’s Test of Sphericity is used to test if the cor-
relation matrix is significantly different from an identity matrix. Fourth, we use Cronbach’s
alpha to measure internal consistency in data under each sub-index. Results of Bartlett’s Test
of Sphericity and Cronbach’s alpha further confirmed that there is reasonable interrelatedness
between variables to create composite indices.
We standardise all indicators in our dataset so that they are rescaled to have 0 mean and
unit standard deviation. We carry out an eigenvalue decomposition of the correlation matrix.
We use the eigenvalue scree plot to determine the number of factors to be retained. We retain
6 factors in exposure that account for nearly 80% variance in original indicators. In sensitivity
and AC, we retain 7 factors each, which explain almost 72.5 and 75% of variance in the origi-
nal indicators, respectively (ESM 1).
We rotate the factors orthogonally to facilitate interpretation of factors. Rotation of factors
also ensures that the extracted factors represent a greater number of variables in the original
dataset. Next, we compute factor scores, which determine the relative placement of observa-
tions on the factor (DiStefano et al. 2009). Since we wanted the index to represent all com-
ponents which contribute significantly to the variance in data, we estimate the value of each
contributing component using the formula described below. We take the sum of all the con-
tributing component values to derive the final index.
(Fi∕TV) × FSi, where Fi is the percentage of variance explained by each factor after
∑
factor rotation, TV is the total variance explained by all retained factors, and FSi is the factor
score coefficients on each factor (Das et al. 2020).
In order to ease interpretation of resulting indices, we normalise the index values by using
the following equation:
{ }
Zi = xi − min (x) ∕{max(x) − min(x)} (i)

The normalised index values lie between 0 and 1.

Note that PCA involves linear transformation of variables. The indices constructed using
PCA represent relative placement of observations in a fewer dimension vector space that cap-
tures maximum variance in data. This implies that the indices should not be interpreted as
scores. The challenges associated with merging datasets and the method used for computing
missing data have been detailed in ESM 1.

4 Results

We have discussed the factor retention process in ESM 1. Post-rotation factor loadings for
exposure, sensitivity, and AC variables have been tabulated in Tables S8, S9, and S10,
respectively. ESM 2 may be referred to for district-wise index values for each of the vul-
nerability components. We divide exposure, sensitivity, and AC into 4 categories — very

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Fig. 1  Map showing exposure index values for 640 Indian districts. Note that 0–0.249 indicates low, 0.25–
0.49 indicates moderate, 0.5–0.749 indicates high, and 0.75–1 indicates very high exposure

Fig. 2  Map showing sensitivity index values for 640 Indian districts. Note that 0–0.249 indicates low, 0.25–
0.49 indicates moderate, 0.5–0.749 indicates high, and 0.75–1 indicates very high sensitivity

high (values from 0.75 to 1), high (values from 0.5 to 0.749), moderate (values from 0.25
to 0.49), and low (values from 0 to 0.249). Figure S2 of ESM 1 shows the percentage of
total population in each individual category of exposure, sensitivity, AC, and vulnerability.

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Climatic Change (2023) 176:154 Page 9 of 20 154

Fig. 3  Map showing AC index values for 640 Indian districts. Note that 0–0.249 indicates low, 0.25–0.49
indicates moderate, 0.5–0.749 indicates high, and 0.75–1 indicates very high AC

Fig. 4  Map showing vulnerability index values for 640 Indian districts. Note that 0–0.249 indicates low,
0.25–0.49 indicates moderate, 0.5–0.749 indicates high, and 0.75–1 indicates very high vulnerability

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Figures 1, 2, 3, and 4 depict district-level exposure, sensitivity, AC, and vulnerability on

the political map of India. The maps were created on the QGIS-LTR application.

4.1 Exposure index

Our findings suggest that 42 districts have very high exposure, 256 districts have high
exposure, 321 districts have moderate exposure, and 21 districts have low exposure. The
298 districts have very high and high-exposure house around 52% of India’s population.
The 321 districts in the moderately exposed districts have 45% of the country’s popula-
tion. The states with the top-10% of high-exposure districts are Rajasthan, Uttar Pradesh,
Himachal Pradesh, Punjab, Delhi, Jammu and Kashmir, Haryana, Uttarakhand, Gujarat,
Chandigarh, Maharashtra, Telangana, Kerala, and Madhya Pradesh. Rajasthan has 15 dis-
tricts in the top-10% exposure category; Uttar Pradesh has 11 districts; Himachal Pradesh
has 8 districts; Punjab has 7 districts; Delhi, Jammu and Kashmir, and Haryana have 4 dis-
tricts each; and Uttarakhand and Gujarat have 3 districts.
Chandigarh is also amongst districts in the top-10% exposure index values. In other
words, our findings denote that Himachal Pradesh has 67% of districts, followed by
Rajasthan, Delhi, Punjab, and Uttarakhand with 45, 44, 35, and 23% of districts in the top-
10% exposure range.

4.2 Sensitivity index

Our results indicate that 17 districts have very high sensitivity, 167 districts have high
sensitivity, 360 districts have moderate sensitivity, and 96 districts have low sensitivity.
Almost 30% of India’s population lives in the 184 districts with very high and high sensi-
tivity. Further, 64% of India’s population lives in the 360 districts with moderate sensitiv-
ity. Uttar Pradesh, Madhya Pradesh, Kerala, Haryana, Odisha, Jharkhand, Punjab, Maha-
rashtra, Rajasthan, Arunachal Pradesh, Puducherry, West Bengal, Andhra Pradesh, and
Gujarat are the states with districts in the top-10% sensitivity range. Uttar Pradesh has 23
districts in the top-10% sensitivity range; Madhya Pradesh has 7 districts; Kerala, Haryana,
and Odisha have 5 districts each; Jharkhand and Punjab have 4 districts each; Maharash-
tra and Rajasthan have 3 districts each; and Arunachal Pradesh, Puducherry, West Bengal,
Andhra Pradesh, and Gujarat have 1 district each in this category. In percentage terms,
Kerala has 36%, Uttar Pradesh has 32%, and Haryana has 24% districts in the top-10%
sensitivity category.

4.3 AC index

With respect to the AC component of vulnerability, our results show that 148 districts have
very high AC, 339 districts have high AC, 146 districts have moderate AC, and 7 districts
have low AC. Around 20% of India’s population lives in 153 districts with moderate and
low AC. The 10% of districts with the lowest AC belong to 13 Indian states. Of these 13
states, Bihar has 11 districts with the least AC and these account for 29% of total districts
in the state. In Jharkhand, 10 districts have the lowest AC and constitute 42% of districts in
the state. Furthermore, 9 districts in Uttar Pradesh, 7 in Arunachal Pradesh, 6 each in Mad-
hya Pradesh and Nagaland, 5 in Manipur, 4 in Assam, 2 in Rajasthan, and 1 each in Jammu
and Kashmir, Chhattisgarh, Himachal Pradesh, and Meghalaya have 10% of the lowest AC.

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Climatic Change (2023) 176:154 Page 11 of 20 154

The three north-eastern states — Manipur, Nagaland, and Arunachal Pradesh — have 56,
55, and 44% districts, respectively, in the lowest 10% AC category. Jharkhand and Bihar
have 42% and 29% districts, respectively, with the least AC index values.
Of the 640 districts, Chandigarh has the highest adaptive capacity. As compared to other
states, Punjab fares best in AC. Of 20 districts, Punjab’s 15 districts have top-10% AC
index values. For 13 districts in Tamil Nadu, which together constitute almost 40.6% of
total districts in the state, AC index values fall in the top-10% category. Kerala’s 6 of 14
districts are in the top-10% AC range. Furthermore, Haryana, Maharashtra, and Delhi have
8, 4, and 3 districts, respectively, in the top-10% category.

4.4 Vulnerability index

According to our results, 38 districts have very high vulnerability, 306 districts have high
vulnerability, 278 districts have moderate vulnerability, and 18 districts have low vul-
nerability. The 344 districts with very high and high-vulnerability house 56% of India’s
population. Further, 42.5% of India’s population lives in the 278 moderately vulnerable
districts. The states with districts in the top-10% vulnerability range are Uttar Pradesh,
Rajasthan, Madhya Pradesh, Jharkhand, Haryana, Himachal Pradesh, Punjab, Uttarakhand,
Jammu and Kashmir, and Arunachal Pradesh. Uttar Pradesh and Rajasthan have 37 and
15 districts, respectively, in the top-10% vulnerability range, Madhya Pradesh has 3 dis-
tricts, Jharkhand and Haryana have 2 districts each, whilst Punjab, Uttarakhand, Jammu
and Kashmir, Himachal Pradesh, and Arunachal Pradesh have 1 district each in this cat-
egory. In percentage terms, this means that 52, 45, and 10% of districts in Uttar Pradesh,
Rajasthan, and Haryana are amongst districts in the top-10% vulnerability range.

4.5 Robustness checks

Our results satisfy all robustness checks. First, uniqueness values, which depict proportion
of variables’ variance that the PCA-derived factors cannot reproduce, are below 0.5 for all
variables (ESM 2). Only the variable depicting the proportion of population belonging to
disadvantaged social groups has a uniqueness value equal to 0.53, which is acceptable in
large datasets. Second, results pertaining to the three indices qualify the test of residuals.
This is because all off-diagonal elements with absolute values greater than 0.05 in the cor-
relation residuals’ matrix are below 40% in each index (ESM 2). Third, the factors derived
from PCA in each index are independent or orthogonal.

5 Discussion

5.1 Probing the results

5.1.1 Exposure index

Our results show that Rajasthan’s 15 districts, which account for 45% of the total districts
in the state, appear in the top-10% of exposed districts. High exposure in these districts is
an outcome of a rapid increase in NLST between 2005 and 2015. For instance, Jodhpur,
Jaipur, and Ajmer, which are amongst the highest-exposed districts in the country, have

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higher and positive differences in NLST between the two time points as compared to other
districts. Annual wind speed in Jodhpur is the highest of all districts, only next to Jorhat
district in Assam. High-exposure districts in Rajasthan such as Bikaner and Churu have
also experienced several disastrous heat waves and cold waves between 1969 and 2019.
In addition to adverse weather extremes and increase in minimum temperatures, Barmer
and Jaisalmer districts recorded the highest PM2.5 in 2015. For Saharanpur, Gautam Bud-
dha Nagar, and Ghaziabad districts, which have the maximum exposure indices in Uttar
Pradesh, higher and positive difference in NLST is accompanied by an increase in mini-
mum temperatures. This phenomenon is also evident in Rajkot, Jamnagar, and Kachchh,
the three most exposed districts in Gujarat.
These findings are consistent with observations in the existing literature. There is evi-
dence that demonstrates that rise in minimum temperature has been more rapid than the
increase in maximum temperature (Gil-Alana 2018). In our study, increase in NLST and
minimum temperatures is indicative of the presence of urban heat island (UHI) effect in
cities. Normally, surface cooling during the night is expected to assuage the increase in
warming. However, high population density and rapid urban growth prevent the process of
nocturnal cooling, thereby leading to an increase in NLST and subjecting urban areas to a
greater number of heat stress nights as compared to rural areas (Chapman et al. 2017). The
underlying cause of high exposure for districts in Himachal Pradesh and Jammu and Kash-
mir is the relatively high and positive difference in rainfall between the two time points. Of
all the northern districts, Shimla witnessed the highest number of disastrous flood events
between 1969 and 2019.
The case of Chandigarh merits attention here. Despite being one of the most well-
planned districts in India, Chandigarh’s high exposure could be attributed to its high
built-up population (as recorded in 2014) and high and positive differences in rainfall and
minimum temperature between 2005 and 2015. This observation is similar to the findings
of Chandan et al. (2020) which suggest that dramatic expansion of built-up population in
Chandigarh between 2008 and 2017 is primarily responsible for increase in land surface
temperature and abnormalities in rainfall.

5.1.2 Sensitivity index

Our results show that 23 districts in Uttar Pradesh have high sensitivity, with Baghpat and
Pilibhit having the highest-sensitivity indices. High sensitivity in Baghpat is a result of
high prevalence of anaemia and diarrhoea in children aged below 5 years, high hospitali-
zation rate due to all causes, high net OOP (all causes) for in-patient treatment, and high
unemployment rate of nearly 13%. Pilibhit owes its high sensitivity to a high prevalence
of stunting and anaemia in children below 5 years, high IMR (53 per 1000 live births),
high hospitalization rate due to CSDs and VBDs, and high net OOP incurred on all causes,
as well as on CSDs and VBDs for IPD treatment. Both Baghpat and Pilibhit have high
shares of per capita monthly health expenditure incurred on the treatment of CSDs and
VBDs. Further, almost 53% and 30% of households in Baghpat and Pilibhit, respectively,
face CHE, which is very high vis-à-vis other Indian districts. For Pilibhit, CHE because
of CSDs and VBDs is the fourth-highest of all districts as nearly 21% of households are
affected by CHE due to CSDs and VBDs.
Dindori, Umaria, and Jhabua districts have the highest sensitivity in Madhya Pradesh.
Both Dindori and Umaria districts report a higher hospitalization rate due to CSDs and
VBDs. Sensitivity in Dindori particularly stems from its very high percentage of BPL

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Climatic Change (2023) 176:154 Page 13 of 20 154

population (third-highest of all districts), which renders it disproportionately susceptible to

CHE incurred on the treatment of CSDs and VBDs. High sensitivity in Umaria is majorly
a result of its high IMR (59 per 1000 live births), high unemployment rate (close to 11%),
and a very high hospitalization rate due to all causes. In Jhabua, high sensitivity is influ-
enced by the high unemployment rate (13%) and very high percentage of population (61%)
which is employed without any social security benefits.
For Sri Muktsar Sahib district in Punjab and Palakkad district in Kerala, the percentage
of population suffering from chronic ailments is estimated at 18% and 10%, respectively.
Unemployment and elderly population are crucial determinants of sensitivity for Palakkad
whilst prevalence of symptoms of ARI is a significant factor behind high sensitivity for Sri
Muktsar Sahib. Both the districts have high percentages of households affected by CHE
due to all causes (36% for Sri Muktsar Sahib and 31% for Palakkad) as well as CSDs and
VBDs (14% for Sri Muktsar Sahib and 15% for Palakkad). For Odisha’s Balangir district,
which has the highest sensitivity index in the state, high CHE attributable to all causes
(afflicting 25.3% of households), employed population bereft of social security (over 26%),
and a very high proportion of population in disadvantaged social groups (99.4%) are fac-
tors contributing to high sensitivity.

5.1.3 AC index

Our findings demonstrate that Kiphire district in Nagaland has the least AC in terms of
dealing with the health impact of climate change. Like other districts in Nagaland such as
Mon and Longleng, the percentage of births attended by skilled health personnel is low
in Kiphere. Healthcare utilization in these districts is low for diarrhoea amongst children
aged below 5 years. Diagnosis of hypertension amongst adults is evidently low in Kiphire.
Further, as compared to other districts, the tendency to seek healthcare from public and
private healthcare facilities is low amongst persons listed to be suffering from tuberculosis
in Kiphire. Whilst these observations could indicate the presence of supply-side inefficien-
cies in healthcare, a potential explanation for low healthcare utilization in Nagaland is that
the state has a high proportion of tribal population. Research has indicated that indigenous
and tribal populations in Nagaland and other states have a higher propensity to utilise tradi-
tional systems of medicine as compared to modern healthcare (Ao 2020).
Dibang Valley and East Kameng districts in Arunachal Pradesh have the least AC after
Kiphire, which is again an outcome of poor health-seeking behaviour. The argument of
low formal healthcare-seeking behaviour in these districts seems convincing because para-
doxically, Kiphire and Dibang Valley have the highest and second-highest ratios of health
facilities and population, respectively, in the country. Dibang Valley and East Kameng are
also amongst districts where the proportion of children who benefitted from Integrated
Child Development Services (ICDS) services is the lowest. Low coverage of ICDS ser-
vices could be responsible for the adverse health and nutritional status of children. Low
percentage of labour force and literacy are also important contributors to the low AC of
East Kameng and Dibang Valley districts. Whilst the low labour force could be regarded as
a result of high outward migration from Arunachal Pradesh, the low literacy rate could be
attributed to high dropout rates in schools (Remesh 2012; Nayak 2013).
In Uttar Pradesh, 9 districts that constitute 13% of the state’s total districts have the
lowest AC. Balrampur, Bahraich, and Shrawasti districts fare worse as compared to other
districts with low AC in the state. The drivers of low AC in Balrampur, Bahraich, and Shra-
wasti have inadequate access to electricity, to improved sanitation, and to clean cooking

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fuel. These districts are also challenged by supply side factors in healthcare systems, such
as insufficient human health resources. Similarly, in Dindori district of Madhya Pradesh,
low AC is a consequence of very low MPCE, lack of improved sanitation facilities, and
clean fuel. Dindori has a very low percentage of within-district hospitalizations and births
attended by skilled healthcare workforce, which draws attention to the deficits in the avail-
ability of healthcare in Dindori. Additionally, low AC is influenced by unfavourable socio-
economic characteristics, which exacerbate deficiencies in healthcare systems.

5.1.4 Climate change and SDH

It may thus be inferred that climate change impacts human health through a complex inter-
play between meteorological, socioeconomic, demographic, and sociopolitical factors.
Given an equivalent level of exposure to climate extremes and DWEs, health vulnerability
of districts is dependent on the resilience of political and health systems, and a range of
socioeconomic and demographic characteristics that impact health. In the SDH conceptu-
alization of health inequities, social and political institutions, such as labour markets and
educational institutions, stratify individuals by education, income, nature of employment,
gender, etc., creating differences in socioeconomic positions of individuals. The differ-
ences in socioeconomic positions influence health status through a host of intermediary
determinants, such as working and housing conditions, relationships, nutrition, and behav-
ioural choices that render individuals susceptible to differential exposure and vulnerability
to adverse health outcomes (Solar and Irwin 2010). Therefore, health vulnerability to cli-
mate change is anchored to the SDH conceptualization. The consequences of health vul-
nerability to climate change and health inequalities may be considered identical.
In addition to adversely affecting human health directly through the pathways described
in Table S4 of ESM 1, climate change impacts human health by exerting a negative influ-
ence on SDH. We illustrate with the help of indicators used in our analysis. A negative
impact on SDH as a result of exposure would imply an unfavourable impact on sensitivity
and AC indicators, which in turn could cause aggravated exposure and vulnerability. For
instance, in addition to increasing the prevalence of CSDs and healthcare expenditures,
an increase in average temperatures could increase the sensitivity of daily wage workers
by adversely affecting socioeconomic factors. Such workers could face a decline in their
earnings as the number of hours they work outdoors become reduced. The economic plight
of workers in the informal workforce is likely to worsen as they lack social security cover-
age. This could impoverish households and cause even low healthcare expenses to become
catastrophic. Abnormal increase in temperature could also increase the prevalence of heat-
related morbidity amongst the elderly and aggravate the condition of the population suf-
fering from chronic ailments. Similarly, climate extremes could inflict serious health chal-
lenges on socially disadvantaged population groups due to high sensitivity and low AC.
Whilst high sensitivity could be attributed to poor nutritional and sub-optimal health status
of such groups, low AC could be an outcome of precarious living conditions, low literacy
rate, and barriers to accessing healthcare. Therefore, in the absence of adequate AC, high
exposure and sensitivity could render districts vulnerable to the health impact of climate
change.
Addressing SDH by increasing AC has the potential to alleviate such impact. This can
be substantiated through our results. For instance, despite high exposure, Chandigarh’s
health vulnerability to climate change is low. This is because the impact of high expo-
sure is mediated by high AC, which is predominantly driven by high MPCE. High MPCE

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Climatic Change (2023) 176:154 Page 15 of 20 154

is associated with better housing conditions, formal workforce, high literacy, and robust
healthcare infrastructure. Similarly, for Thiruvananthapuram district in Kerala, the impact
of high exposure and high sensitivity (due to high prevalence of chronic ailments, high
percentage of population aged 60 years and above, and high hospitalization rate) is coun-
teracted by high AC, subsequently resulting in lower vulnerability vis-à-vis other districts.
High AC in Thiruvananthapuram is mainly influenced by improved socioeconomic charac-
teristics of households (improved sanitation and high MPCE), adequate healthcare infra-
structure (denoted by high within-district hospitalizations) and healthcare human resources
(high-skilled birth attendance), and better healthcare performance (depicted by higher per-
centage of TB treatment).

5.2 Policy implications

Whilst a universal set of approaches is required to reduce exposure and sensitivity and
increase AC, targeted approaches are needed depending upon the causes of vulnerabil-
ity in districts. ‘Low’ vulnerability or ‘low’ sensitivity does not imply that no response is
required. It only indicates that in terms of implementing universal interventions, such dis-
tricts could receive relatively lower priority in policymaking. Furthermore, since climate
exposure varies across districts, health system responses to climate change cannot be uni-
form across districts. As we discuss further, the need for local responses to mitigate health
vulnerability is crucial.

5.2.1 Contextual/local responses

Local responses are crucial to address context-specific factors that exacerbate health vul-
nerability. Our analysis enables us to identify factors that aggravate vulnerability in dis-
tricts. For example, high sensitivity in districts of Uttar Pradesh, Madhya Pradesh, Punjab,
and Odisha is a consequence of high OOP and CHE expenditure, which is a result of lim-
ited public spending on health, inadequate risk-pooling mechanisms, and weak and frag-
mented health systems. High OOP expenditure forces people to depend on their own means
to seek healthcare. High sensitivity in certain districts of these states is also an outcome of
informal employment structures with limited access to social security benefits. Employ-
ment in informal jobs often leaves a considerable section of the population entrenched in
poverty and vulnerability. Any small shock, such as ill-health and CHE caused by climate-
induced exposure, is likely to push such population further below the poverty line.
Identification of underlying causes of sensitivity could help in identifying appropriate
responses. For example, increasing public expenditure on health could have a significant
impact on reducing OOP and sensitivity. Improving inequalities in the distribution of SDH
could also reduce health vulnerability in these districts by improving both the education
status of the population and its employability, which in turn could contribute to reducing
sensitivity and enhancing AC. In the short run, the importance of concerted efforts of local
governments in providing social safety nets and improving adaptation of vulnerable popu-
lation has been recognised in certain countries like Brazil (Menezes et al. 2018). Moreover,
proactive civil society and community participation in strengthening bottom-up planning
could play an instrumental role in improving AC and reducing vulnerability. This could be
done by promoting the uptake of ICDS, primary care, and formal health-seeking behaviour
amongst the population.

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154 Page 16 of 20 Climatic Change (2023) 176:154

Poorly developed primary healthcare remains a major factor behind high sensitivity in
some districts which report high IMR and poor child health indicators. Robust primary
healthcare has shown promise in effectively addressing preventable causes of mortality and
morbidity in many Indian states like Kerala and Tamil Nadu. Primary healthcare systems
also have the potential to address the impending burden of NCDs and communicable dis-
eases in the country, which is likely to aggravate as a result of climate change. By facilitat-
ing early disease diagnosis, primary healthcare can reduce curative healthcare spending,
the latter being catastrophic for a huge section of the Indian population (Garg and Karan
2009; Ghosh 2011).

5.2.2 Need for Complex Adaptive Systems (CAS)

It is important to introduce the Complex Adaptive Systems (CAS) approach to understand

the complexity of climate change and health systems. The CAS approach casts doubt on
simple cause-and-effect relationships and calls for strengthening the understanding of the
dynamic nature of systems. Systems can be complex when they are constituted by a net-
work of agents who act continuously and simultaneously to respond to other agents. Such
non-linear interactions amongst agents exert influence on the functioning of individual
agents and the entire network. Furthermore, since systems are situated within an environ-
ment which is susceptible to change, systems too can change their interactions to adapt to
the changes in the environment (The Health Foundation 2010).
Climate change and health systems may both be perceived as CAS because they interact
with multiple agents within their respective networks and environments. Both systems are
dynamic and adapt and evolve with changes in the environment. Climate change involves
continuous interactions of societies, ecosystems, and biophysical elements. Health sys-
tems are governed by interactions between patients, insurance agents, healthcare facili-
ties, entrenched and diverse network of providers, and disease dynamics. Moreover, both
systems interact with each other — climate change impacts health systems, which in turn
affect climate change by increasing the carbon footprint. Given continuously changing and
evolving dynamics in climate change, morbidity and mortality patterns, and health sys-
tems, VAs and strengthening SDH should not be viewed as endpoints to tackle the health
impact of climate change. In fact, VAs and SDH should integrate mechanisms to account
for recurrent interactions within and between CAS.
One possible way of addressing the unpredictability that may accrue as a result of these
interactions is by building more resilient health systems. Whilst robust disease surveillance
systems that can predict shocks like DWEs are the cornerstone of resilient health systems,
introducing mechanisms to make health systems adaptable are crucial for timely and effec-
tive interventions during crises. In addition to delivering an adequate level of healthcare
services, adaptability in health systems ensures responsive policymaking and realignment
of resources and functions to respond to shocks in a way that does not affect the function-
ing of routine and emergency services (Blanchet et al. 2017). CAS thinking is critical for
understanding the implications of climate change and human health and develop locally
appropriate responses.

5.3 Limitations

The present study suffers from certain limitations. First, the DWE data was collated
from hazard maps of IMD, which made it practically impossible to cover all frequencies/

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intensities of DWEs. Due to this limitation around data accessibility, we could only include
DWEs for the three extreme categories and omit two categories of low and very low num-
ber of DWEs (disastrous heat wave days, cold wave days, and flood events) or low and
very low wind speed. Second, in the estimation of CHE on VBDs, only expenditure on
IPD treatment could be considered. Expenditure incurred on OPD treatment could not be
included in the calculation of CHE due to differences in reference periods — OPD expend-
iture has a reference period of 15 days whilst VBDs have a reference period of 365 days.
Therefore, CHE on CSDs and VBDs could have been possibly underestimated. Third, dis-
tricts formed after the 2011 Census were omitted to maintain a consistent number of dis-
tricts across datasets.
Fourth, data for a number of variables has been sourced from the 75th round of the
National Sample Survey (NSS, conducted in 2017–2018), which is the latest sample survey
to study health-seeking behaviour and out-of-pocket expenditure. For computing the final
vulnerability index based on exposure, sensitivity, and AC, we wanted all years to be in
proximity to 2017–2018. Hence, the most recent year for including meteorological vari-
ables was decided to be 2015. Although a 20- or 30-year interval would have been better
to capture the extent of changing climate, district-level meteorological data prior to 2005
was not accessible from geospatial covariates’ dataset of the DHS. Using more recent data
sources could be better from a practical perspective. Fifth, we could not include indicators
that represent social networks, sociopolitical systems, projected climate change, and other
projected data in our study. Last, our indicator selection is backed by comprehensive lit-
erature review, and the use of PCA led to an objective weighting of components. However,
our results could be sensitive to indicator selection since we could not check for robustness
using a different dataset due to limitations on data availability in developing countries.
Future research on VAs can address these lacunae.
The shortcomings associated with data sources used in the paper merit attention. First,
since NSS involves self-reporting of ailments and healthcare expenditures, there could be
recall bias in reporting of these indicators. The probability of recall bias could be higher in
reporting of indicators which have a reference period of 365 days. Therefore, IPD-related
indicators could suffer from inaccuracies due to the lengthy recall period. Problems linked
with recall bias have also been reported for NFHS. However, due to shorter recall period
for most indicators, the degree of recall bias is comparatively less for NFHS. Second,
whilst efforts have been made to estimate multi-morbidity data using NSS, we could not
estimate such data for our analysis because the complexities associated with multi-morbid-
ity are not effectively recorded in NSS (Karan et al. 2022). Third, data collected in large-
scale sample surveys such as NSS, NFHS, and PLFS may suffer from quality issues due
to interviewers’ bias. Fourth, although a correspondence between ailments listed in NSS,
ICD-10, and ICPC-3 was meticulously established, there could be some degree of error in
the methodology used to assign codes to ailments classified in NSS.
Certain challenges linked to VAs in general must be highlighted. First, since there is no
standard method to calculate vulnerability, caution should be exercised in comparing VA
results from two or more sources. This could limit the possibility of longitudinal compari-
son of VA results. Second, uncertainties associated with the rapidly changing climate pro-
vide basis for near-real-time surveillance of health status and meteorological variables for
smallest administrative units. However, in the absence of robust data systems in developing
countries, the use of VAs is recommended in conjunction with real-time contextual factors.

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6 Concluding observations

This paper makes an important contribution to the limited literature on climate change
and health vulnerability in the Indian context. It uses the vulnerability conceptualization
of IPCC’s AR4 and brings together 50 variables from 8 data sources to estimate health
vulnerability to climate change for 640 Census 2011 Indian districts. The final vulner-
ability index is based on independently estimated exposure, sensitivity, and AC indices.
Our results indicate that 56% of India’s population in 344 districts is highly vulnerable
to the health impact of climate change. Furthermore, there are 298 districts with high
exposure which house around 52% of India’s population and 184 districts with high sen-
sitivity that house 30% of the country’s population.
A disaggregated analysis of vulnerability in this paper has brought to the fore the
underlying causes of health vulnerability. High OOP and CHE, an outcome of weak
and fragmented health systems that are characterised by inadequate public spending and
risk-pooling mechanisms, informal employment structures which lack access to social
security benefits, and poorly developed primary care which is incapacitated in address-
ing preventable causes of morbidity and mortality, have been identified as crucial driv-
ers of higher sensitivity. The results also highlight that high exposure and sensitivity in
certain districts is mediated by an equally high AC, which has resulted in low vulner-
ability for such districts. Such examples provide us with some insights for future policy
impetus.
Since climate exposure varies across districts, we argue that health system responses
to climate change should vary by districts depending upon the causes of vulnerability.
We highlight the need for CAS thinking in order to better understand the implications
of climate change and human health and develop locally appropriate responses, with
particular focus on strengthening primary health systems through bottom-up planning.
Supplementary Information The online version contains supplementary material available at https://​doi.​
org/​10.​1007/​s10584-​023-​03630-0.

Acknowledgements We are grateful to Prof. Sagnik Dey, Chair Professor, Centre for Atmospheric Sci-
ences, IIT Delhi for sharing district-level data on PM2.5. We would like to extend our gratitude to Mr. E
Lokesh Kumar for guiding us through QGIS. We also wish to thank Ms. Sameeha Jameel for collating data
on DWEs. Thanks are due to the Research and Ethics Review Board (RERB) at JGU for reviewing and
approving the RERB application for this study.

Author contribution Both authors contributed to the study conception and design. Data estimation, colla-
tion, and analysis were performed by D. C. and supervised by I. M. The original draft was written by D. C.
Both authors contributed to the subsequent versions of the manuscript. Both authors read and approved the
final manuscript.

Data availability This publication is supported by multiple datasets, which are openly available at locations
cited in the Reference section.

Declarations
Ethics approval Since this article is based on secondary data sources which are publicly available and have no
household or individual identifiers that could violate the confidentiality of respondents, it was exempt from
ethics approval by the RERB at JGU.

Conflict of interest The authors declare no competing interests.

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Climatic Change (2023) 176:154 Page 19 of 20 154

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