Heat action plans in eight Indian cities: Knowledge gaps & opportunities for intersectoral heat governance

Study period

The data were collected from sources and documents in the public domain. No identifiable data of individuals or biological or environmental sampling was involved.

Analytical framework

The study assesses eight city-level HAPs in India, benchmarking the contents of the HAPs against the eight core elements of heat-health action planning identified in WHO/Europe’s guidance document for heat-health action planning. It further identifies and assesses the core elements by sub-elements adapting the indicator-based approach²², which linked sub-elements to the core elements developed under the EuroHEAT project. The document text corresponding to the core elements was also analysed using the text analysis method, to complement and validate the key findings.

The analysis was done in three stages. First, an iterative review of the selected HAPs was conducted to finalise city-specific sub-elements and identify key words for the textual analysis. Second, a colour-coded data extraction form was developed and completed, capturing the findings from the analysis of the HAPs. Third, a text analysis was conducted with the help of identified key words to complement the findings from the review. The researchers adopted a consensus-based approach for the first and second stages. The details are presented below.

An iterative protocol was developed for an initial review of the HAPs, to build familiarity with their structure and content. Four members (RD, PD, AM, GS) in the research team reviewed the HAPs independently and iteratively until all members agreed on the best representation of the data. The team members collaborated on the principle of ‘mutual respect, equal involvement, and shared power’^23,24. This led to modifications in the sub-elements to reflect city-level specificities, since originally²² these were intended for characterizing national level plans. The sub-element ‘inclusion in national disaster preparedness’ was changed to ‘inclusion in disaster preparedness,’ ‘cross-border cooperations’ was changed to ‘synchronicity with district- and State- level plans’ and ‘involving data from >1 region/city’ was changed to ‘involving data from >1 ward’, since wards are the administrative divisions within a city. ‘Changes to water supply management’ was added as a sub-element for the core element of ‘long-term urban planning’, as water supplies are critical for managing extreme heat conditions in Indian cities. Table I provides an overview of the core elements, their sub-elements and key words identified for text analysis.

Three distinct classifications for the characterisation of content on elements and sub-elements emerged from the review. A colour-coded labelling system was accordingly developed to reflect these categories depending on whether there was (i) no mention of the sub-element (light blue), (ii) mention without any actionable details and/or guidance for implementation (dark blue) and (iii) mention that is elaborated upon with actionable details and/or guidance for implementation (navy blue). The no mention category includes instances where a key word from the sub-element is used without supportive text to develop the sub-element. Data were extracted to a form designed in Microsoft Office Excel. Subsequently, a sub-set of two researchers independently reviewed each HAP to classify its contents in terms of the sub- elements represented in it (or its lack thereof). This action was repeated over two rounds to confirm agreement (or lack of it where it persisted). Feedback sessions were held with the larger research team after each round and inputs incorporated. Consensus was reached on the labelling attributed to each element and sub-elements by the end of the second round.

The researchers drew upon their careful reading of the documents in the first two stages and the enumeration of relevant keywords to conduct a text-analysis²⁵. Text analysis was conducted using R software to study the frequency of use of words in the HAPs and key words corresponding to the core elements. The ten most frequently used words were identified for each of the HAPs, expressed as a percentage of the total number of words in the respective HAP to probe on the variability of usage. Key words were identified for each core element in the WHO/Euro guidance. The frequency of these were then examined in each HAP using text analysis. Text analysis is employed as a complementary tool to the primary benchmarking process, rather than as a standalone method for determining word significance. An iterative approach was adopted, involving repeated cycles of text analysis and document review. The soft copies of the HAP were searched with the keywords, so that we could see the sentences, paragraphs and sections within which these keywords were used. This ensured that the contextual use of keywords was assessed for relevance to specific sub-themes, further validating the findings.

Selection of HAPs

The national government is working with several States, districts and cities in developing HAPs. A recent estimate suggests that there are over 130 cities and districts involved in the process²⁶. Most HAPs are at different stages of development and revisions, and hence unavailable in the public domain or in one database. For the present study, publicly accessible city-level HAPs at the time of the study were accessed using a desktop search-engine based strategy (Google search engine) along with reviewing previous studies and grey literature regarding HAP development in India^21,27. For the analysis, two criteria were considered for selection of HAPs. Firstly, the HAP had to be titled as either a ‘heat action plan’, ‘heatwave action plan’ or specifically mention in the title page that it addresses extreme heat or heatwave response planning. Secondly, it was also required that the HAP be an official policy document, owned by the concerned city administration and approved for implementation.

Out of 10 city-level HAPs that met these criteria at the time of the analysis, eight could be fully accessed. Two HAPs (for the cities of Gondia and Chandrapur) could not be accessed fully and were therefore not considered for the analysis. The issuing authority, partners of the HAPs and sources of HAPs are presented as supplementary table. It is to be noted that the selection process is internally consistent in keeping with the objective, which is to examine the presence of different components in each individual HAP.

Agreement on a lead body and clear definition of actors’ responsibilities

The responsibility for HAPs is vested with the National Disaster Management Authority (NDMA) at the national level. For cities, the corresponding State disaster management authority leads heat governance. The text analysis confirms the significance of the India Meteorological Department (IMD) and the NDMA. It also demonstrates variability in the frequency for some key words, such as ‘disaster’, where usage ranges from zero occurrence (Ahmedabad) to very high occurrence (Vadodara). Emphasis on the designated lead body (Delhi) and on assigned roles can be strengthened (Vadodara). The Delhi HAP identified relevant actors and assigned responsibilities. Some HAPs mandated the establishment of committees for implementation (Heatwave Task Force, Thane Municipal Corporation; Heatwave Plan Implementation Committee, Jodhpur; Steering Committee for Medical Emergency Preparedness, Bhubaneswar). Surat and Thane cover all the sub-elements. Alignment with district- and State-level institutional mechanisms and plans falls short in all the others. Three HAPs mention inclusion and disaster preparedness, but lack actionable guidance.

Accurate and timely alert systems

All HAPs perform well on this element, though Vadodara has scope for significant improvement. The Ahmedabad, Rajkot and Bhubaneswar HAPs cover key aspects of heat-health alert systems (scientifically sound threshold definition, regionally adapted definition, advanced warning, graded level of alerts and communication plan). Notably, five HAPs are strong in having different levels of actions for different levels of alerts. For some HAPs, communication plans need improvement (e.g., Delhi HAP). IMD definitions for heatwaves prevail across HAPs, with some variations in the definition of heat thresholds adapted to local contexts. For instance, the Thane HAP provides locally determined felt temperature thresholds based on the heat index to indicate the impact of humidity in addition to dry temperature. The text analysis confirms high levels of similarity in the usage and frequency pattern of key words.

Health information plans

‘Health information plans’ was the best-represented core element with all sub-elements being mentioned in every HAP. Information was generally geared towards medical professionals. Ahmedabad and Jodhpur have scope to improve on quality of advice with more guidance, and Vadodara in terms of information campaigns. In terms of frequency of specific key words, the five HAPs which excel in performance are highly similar. Relatively higher variation is seen in frequency of key words amongst Ahmedabad, Vadodara and Jodhpur.

Reduction in indoor heat exposure

Among the sub-elements, insulation is not covered well in 4 HAPs. There is scope for improvement in providing advice on tackling exposure in the Vadodara HAP. Except for one HAP, improved albedo/shading is well covered. Specific programmes for cool roofs and cool spaces using white reflective paint are also included. On the sub-theme of provision or use of cooling equipment all HAPs mention fans and/or coolers. The Rajkot HAP mentions rise in interpersonal violence due to rising temperatures. Bhubaneswar, Thane, Delhi and Rajkot excel in this core element. Findings from the text analysis are complementary, displaying high levels of similarity in usage and frequency of key words, in these four HAPs.

Caring for vulnerable groups

Identification of vulnerable communities is a key pre-requisite for public health interventions. The HAPs tend to fall short in this aspect. The needs of vulnerable groups are dynamic, and regular re-assessments are required alongside ongoing monitoring for active responses. The HAPs lacked mention of such periodic assessments and follow ups. Methodologies or protocols to identify vulnerable groups are required. Four HAPs provide information on why particular groups are vulnerable to heat-health risks. Thane and the Bhubaneswar conducted vulnerability assessments to identify vulnerable city wards in the formative phase. The Rajkot HAP mentions delivering targeted interventions for vulnerable groups. The Bhubaneswar plan specifically focuses on gender (Box). Textual analysis reveals less/no mention of ‘disabled’ and ‘homeless’ across the HAPs, while ‘children’ and ‘elderly’ are well covered by nearly all the HAPs.

Preparedness of health/social care systems

The HAPs lack information on at least one of the sub-elements under this core element. Two HAPs make mention of ‘heat reduction in health facilities’ and ‘special precautions in nursing homes.’ Suggested interventions include the setting up of air-conditioned wards and cool wards (Delhi, Bhubaneswar). Interventions for health care institutions include provision of drinking water (Ahmedabad) and organizing workshops for staff members and health care professionals (Rajkot). The other sub-elements (‘increase in capacity of health services, ‘special resources for people/public’, ‘improving healthcare networks’) are well represented across HAPs, albeit with heterogeneity in terms of the actions covered under them.

Long-term urban planning

Long-term measures are poorly represented in most HAPs, except for Thane and Delhi. While ‘increase in green and blue spaces’ and ‘changes in building design’ are covered in most HAPs, interventions that require more complex decision-making by public authorities and are shaped more explicitly by political factors such as ‘changes in land-use decisions’ are less represented. The Thane HAP, highlights heat risk informed urban planning for mitigating future heat risks.

Real-time surveillance and evaluation

Surveillance data is required for the monitoring of health impacts of heatwaves and to inform decision-makers in evaluating and selecting HAP measures. While six HAPs had a component on surveillance, the use of surveillance data for dynamic adjustment of measures found mention in three HAPs. The use of surveillance data for the evaluation of the effectiveness of the HAP finds mention in all plans. Thane provided a monitoring and evaluation framework to carry out evaluation activities on an annual basis. Thane, Jodhpur and Delhi have relatively better coverage, especially in ‘use for adjustment of measures’ sub-element, which has no mention in the other HAPs. However, there is scope to improve and strengthen guidance across all HAPs.