Dileep Mavalankar

Heat-Related Mortality in India: Excess All-Cause Mortality Associated with the 2010 Ahmedabad Heat Wave

Introduction In the recent past, spells of extreme heat associated with appreciable mortality have been documented in developed countries, including North America and Europe. However, far fewer research reports are available from developing countries or specific cities in South Asia. In May 2010, Ahmedabad, India, faced a heat wave where the temperatures reached a high of 46.8°C with an apparent increase in mortality. The purpose of this study is to characterize the heat wave impact and assess the associated excess mortality. Methods We conducted an analysis of all-cause mortality associated with a May 2010 heat wave in Ahmedabad, Gujarat, India, to determine whether extreme heat leads to excess mortality. Counts of all-cause deaths from May 1–31, 2010 were compared with the mean of counts from temporally matched periods in May 2009 and 2011 to calculate excess mortality. Other analyses included a 7-day moving average, mortality rate ratio analysis, and relationship between daily maximum temperature and daily all-cause death counts over the entire year of 2010, using month-wise correlations. Results The May 2010 heat wave was associated with significant excess all-cause mortality. 4,462 all-cause deaths occurred, comprising an excess of 1,344 all-cause deaths, an estimated 43.1% increase when compared to the reference period (3,118 deaths). In monthly pair-wise comparisons for 2010, we found high correlations between mortality and daily maximum temperature during the locally hottest “summer” months of April (ru200a=u200a0.69, p<0.001), May (ru200a=u200a0.77, p<0.001), and June (ru200a=u200a0.39, p<0.05). During a period of more intense heat (May 19–25, 2010), mortality rate ratios were 1.76 [95% CI 1.67–1.83, p<0.001] and 2.12 [95% CI 2.03–2.21] applying reference periods (May 12–18, 2010) from various years. Conclusion The May 2010 heat wave in Ahmedabad, Gujarat, India had a substantial effect on all-cause excess mortality, even in this city where hot temperatures prevail through much of April-June.

Development and implementation of South Asia's first heat-health action plan in Ahmedabad (Gujarat, India).

Recurrent heat waves, already a concern in rapidly growing and urbanizing South Asia, will very likely worsen in a warming world. Coordinated adaptation efforts can reduce heat’s adverse health impacts, however. To address this concern in Ahmedabad (Gujarat, India), a coalition has been formed to develop an evidence-based heat preparedness plan and early warning system. This paper describes the group and initial steps in the plan’s development and implementation. Evidence accumulation included extensive literature review, analysis of local temperature and mortality data, surveys with heat-vulnerable populations, focus groups with health care professionals, and expert consultation. The findings and recommendations were encapsulated in policy briefs for key government agencies, health care professionals, outdoor workers, and slum communities, and synthesized in the heat preparedness plan. A 7-day probabilistic weather forecast was also developed and is used to trigger the plan in advance of dangerous heat waves. The pilot plan was implemented in 2013, and public outreach was done through training workshops, hoardings/billboards, pamphlets, and print advertisements. Evaluation activities and continuous improvement efforts are ongoing, along with plans to explore the program’s scalability to other Indian cities, as Ahmedabad is the first South Asian city to address heat-health threats comprehensively.

A cross-sectional, randomized cluster sample survey of household vulnerability to extreme heat among slum dwellers in ahmedabad, india.

Extreme heat is a significant public health concern in India; extreme heat hazards are projected to increase in frequency and severity with climate change. Few of the factors driving population heat vulnerability are documented, though poverty is a presumed risk factor. To facilitate public health preparedness, an assessment of factors affecting vulnerability among slum dwellers was conducted in summer 2011 in Ahmedabad, Gujarat, India. Indicators of heat exposure, susceptibility to heat illness, and adaptive capacity, all of which feed into heat vulnerability, was assessed through a cross-sectional household survey using randomized multistage cluster sampling. Associations between heat-related morbidity and vulnerability factors were identified using multivariate logistic regression with generalized estimating equations to account for clustering effects. Age, preexisting medical conditions, work location, and access to health information and resources were associated with self-reported heat illness. Several of these variables were unique to this study. As sociodemographics, occupational heat exposure, and access to resources were shown to increase vulnerability, future interventions (e.g., health education) might target specific populations among Ahmedabad urban slum dwellers to reduce vulnerability to extreme heat. Surveillance and evaluations of future interventions may also be worthwhile.

An evaluation of two large scale demand side financing programs for maternal health in India: the MATIND study protocol

BackgroundHigh maternal mortality in India is a serious public health challenge. Demand side financing interventions have emerged as a strategy to promote access to emergency obstetric care. Two such state run programs, Janani Suraksha Yojana (JSY)and Chiranjeevi Yojana (CY), were designed and implemented to reduce financial access barriers that preclude women from obtaining emergency obstetric care. JSY, a conditional cash transfer, awards money directly to a woman who delivers in a public health facility. This will be studied in Madhya Pradesh province. CY, a voucher based program, empanels private obstetricians in Gujarat province, who are reimbursed by the government to perform deliveries of socioeconomically disadvantaged women. The programs have been in operation for the last seven years.Methods/designsThe study outlined in this protocol will assess and compare the influence of the two programs on various aspects of maternal health care including trends in program uptake, institutional delivery rates, maternal and neonatal outcomes, quality of care, experiences of service providers and users, and cost effectiveness. The study will collect primary data using a combination of qualitative and quantitative methods, including facility level questionnaires, observations, a population based survey, in-depth interviews, and focus group discussions. Primary data will be collected in three districts of each province. The research will take place at three levels: the state health departments, obstetric facilities in the districts and among recently delivered mothers in the community.DiscussionThe protocol is a comprehensive assessment of the performance and impact of the programs and an economic analysis. It will fill existing evidence gaps in the scientific literature including access and quality to services, utilization, coverage and impact. The implementation of the protocol will also generate evidence to facilitate decision making among policy makers and program managers who currently work with or are planning similar programs in different contexts.

Statewide program to promote institutional delivery in Gujarat, India: who participates and the degree of financial subsidy provided by the Chiranjeevi Yojana program

BackgroundThe Chiranjeevi Yojana (CY) is a large public-private partnership program in Gujarat, India, under which the state pays private sector obstetricians to provide childbirth services to poor and tribal women. The CY was initiated statewide in 2007 because of the limited ability of the public health sector to provide emergency obstetric care and high out-of-pocket expenditures in the private sector (where most qualified obstetricians work), creating financial access barriers for poor women. Despite a million beneficiaries, there have been few reports studying CY, particularly the proportion of vulnerable women being covered, the expenditures they incur in connection with childbirth, and the level of subsidy provided to beneficiaries by the program.MethodsCross-sectional facility based the survey of participants in three districts of Gujarat in 2012–2013. Women were interviewed to elicit sociodemographic characteristics, out-of-pocket expenditures, and CY program details. Descriptive statistics, chi square, and a multivariable logistic regression were performed.ResultsOf the 901 women surveyed in 129 facilities, 150 (16xa0%) were CY beneficiaries; 336 and 415 delivered in government and private facilities, respectively. Only 36 (24xa0%) of the 150 CY beneficiaries received a completely cashless delivery. Median out-of-pocket for vaginal/cesarean delivery among CY beneficiaries was

Initial results on the impact of Chiranjeevi Yojana: a public–private partnership programme for maternal health in Gujarat, India

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Heat Wave Vulnerability Mapping for India

71. The median degree of subsidy for women in CY who delivered vaginally/cesarean was 85/71xa0% compared to out-of-pocket expenditure of

Metabolized‐Water Breeding Diseases in Urban India: Sociospatiality of Water Problems and Health Burden in Ahmedabad City

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Intensity of contact with frontline workers and its influence on maternal and newborn health behaviors: cross-sectional survey in rural Uttar Pradesh, India

208 for vaginal/cesarean delivery paid by non-program beneficiaries in the private health sector.ConclusionsCY beneficiaries experienced a substantially subsidized childbirth compared to women who delivered in non-accredited private facilities. However, despite the government’s efforts at increasing access to delivery services for poor women in the private sector, uptake was low and very few women experienced a cashless delivery. While the long-term focus remains on strengthening the public sector’s ability to provide emergency obstetric care, the CY program is a potential means by which the state can ensure its poor mothers have access to necessary care if uptake is increased.

Development of Ahmedabad’s Air Information and Response (AIR) Plan to Protect Public Health

Abstract Background Launched in 2006, Chiranjeevi Yojana (CY) is a large performance-based financing programme in Gujarat, India, which aims to provide free delivery care for poor and tribal women. The programme capitalises on the huge private health sector in the state and offers accredited private hospitals a fixed payment for providing free maternity services to vulnerable women. To date, more than 600u2008000 women have benefited from the programme. However, there has not been a systematic state-wide impact evaluation. The goal of this study is to explore the effect of CY on public–private maternal health service provision and on maternal mortality. Methods Based on data obtained from the Health Management Information System (HMIS), we assessed the effect of CY on public and private institutional deliveries across all districts from 2006 to 2010. In addition, we evaluated the programmes impact on maternal mortality by examining the association between maternal mortality ratios (MMR) and the proportion of CY-supported deliveries at the district level. A mixed effects regression model, which takes into account various socioeconomic variables, was applied. Findings Institutional deliveries in Gujarat increased by 23·8%, from 818u2008398 of 1u2008200u2008473 deliveries (68·2%) in 2006 to 1u2008071u2008653 of 1u2008164u2008841 (92·0%) in 2010. Over 99% (251u2008061 of 253u2008254) of the overall increase occurred in the private sectors. The proportion of CY-supported deliveries among all private institutional deliveries increased from 9·3% (47u2008706 of 510u2008343) in 2006 to 19·8% (150u2008979 of 761u2008408) in 2010. Results from the regression analysis suggested that the impact of CY varied considerably across districts. Significant association between MMR and CY-supported deliveries was found in a few districts. Interpretation This study is the first to systematically explore the state-wide impact of CY. Considering the dominant role played by the private health sector in India, the findings indicate that the private–public partnership schemes can potentially be an effective strategy for enhancing maternal health-care access. Nevertheless, the current study is subject to limitation in data quality, and further studies are required. Funding EU FP7 MATIND. HMIS data were provided by the Gujarat State Department of Health. The funding source or the State Department of Health had no role in the study design; data gathering, analysis, and interpretation; decision to publish; or writing of the report. The corresponding author had full access to all the data and had the final responsibility for the decision to submit for publication.