Purnamita Dasgupta

Decline in immunization coverage across well-performing districts in India: an urban conundrum?

Inequities in immunization persist in India in spite of the established importance of the national immunization program in preventing deaths, disability and morbidity arising from vaccine preventable diseases (VPDs) [1]. The role of programmatic complexities, political and social contexts as determinants of immunization has been explored in understanding why these inequities exist [2]. The DLHS3 reported a decline in the proportion of fully immunized children (12–23 mo) in several states which had been reporting high overall state level immunization coverage [3]. Possible explanations include the adverse impact of the polio eradication campaign, and social resistance in some states such as Tamil Nadu and Kerala due to reports of deaths and Adverse Events Following Immunization (AEFI) [4]. These explanations seem inadequate as the states reporting declines in full immunization coverage were nonendemic for polio and had only one or two pulse polio rounds annually, while the scale of AEFI is not large enough [5]. In this study the authors apply an alternative methodological approach, namely, the area effects framework, to analyze a combination of individual and socio-economic factors that can effectively explain the variations in the observed decline in district-level immunization coverage. The area effects framework, consisting of compositional, collective and contextual factors was applied to explain variations in immunization coverage observed at the district level between the two rounds of the DLHS survey (rounds 2 and 3) [6]. The factors selected were (i) household factors: educational attainment and poverty status; (ii) factors that influence local physical and social environment: distance from nearest town, availability and accessibility of health infrastructure, and urbanization; (iii) community-level contextual factors: religion, caste and tribe. The empirical analysis uses a logistic regression to identify the significant explanatory factors that can explain the observed decline in coverage. Empirical district level data on explanatory factors was taken from DLHS3 (2007–8). Good governance at state level is expected to play a key role in successful implementation of the immunization program. Consequently, nine states were selected for the analysis where several districts have reported declines, despite being states deemed to have good governance in terms of their performance in several socio-economic aspects such as infrastructure availability, law and order, judicial services, and educational achievements [7]. These states are Punjab, Haryana, Andhra Pradesh, Tamil Nadu, Gujarat, Karnataka, Maharashtra, Kerala, and Himachal Pradesh. The analysis was done for all the districts (206 districts) in these nine states. Districts which report a decline in immunization coverage between DLHS2 (2002–04) and DLHS3 (2007–08) were defined as decline districts and the rest served as the control districts in each selected state. The proportion of fully immunized children as per the Government of India’s national immunization program was the indicator used for judging the coverage achieved in each district. Nearly 58 % (119) districts of a total of 206 districts in these nine states reported a decline in coverage of fully immunized children in DLHS3 as compared to DLHS2.Within a state, the highest proportion of districts reporting a decline was from Tamil Nadu at 87 %, where 26 out of the 30 districts covered in the survey reported a decline (Fig. 1). In two of the nine states, Punjab and Maharashtra, disparity in coverage across districts increased between DLHS2 and 3. The extent R. Dasgupta (*) Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi 110067, India e-mail: dasgupta.jnu@gmail.com

Understanding Associations: Health, Socio-economic Wellbeing and Climate

Reducing risks from current and projected threats from climate change in a developing economy requires an in depth understanding of the associations between health status, climatic events and development. This is particularly important since up to mid Century, climate change is expected to act mainly by exacerbating health problems that already exist. Adaptation under these circumstances, especially for populations that do not have access to health care and public health services, is as much a question of responding to an amplification of existing threats to public health as of new strategies for managing new threats. To illustrate the point, an analysis of secondary data for one state in India is undertaken. The risk posed by climate events to mortality and economic losses, are statistically analysed. District level indices of health care provision and socio-economic status are constructed for 18 districts of the state over a period of 12 years from 2002–03 to 2013–14. The statistical associations between risk of mortality from climate events, health sector preparedness and socioeconomic wellbeing are subsequently highlighted.

Evaluating expert opinion on India's climate policy: opportunities and barriers to low-carbon inclusive growth

In 2009, India set a voluntary target of reducing the emission intensity of GDP by 20–25% below 2005 levels by 2020, a commitment to be met while ensuring that poverty alleviation and economic growth are not compromised. This paper presents findings from an analysis of expert opinions on Indias domestic climate policy, the opportunities and bottlenecks in transitioning to a low-carbon inclusive growth paradigm, with special emphasis on two key energy intensive sectors, transport and power. The findings reveal a consensus among experts that, while India has successfully initiated several programmes for ensuring development of its economy along low-carbon pathways, achieving a desirable level of emission reduction constitutes a challenge. Ensuring that a broader development agenda remains viable while constructively addressing emissions calls for changes in a number of complementary policy factors. Inadequacy of the current institutional structure, inadequate financial resources, inefficient subsidy systems, limited opportunities for global partnership and over-reliance on regulatory approaches for reducing carbon emissions limit the success of announced climate policy measures. India can overcome its huge backlog of infrastructure requirements by adopting a low-carbon growth path in transport and power sectors in particular. Declarations of energy and climate priorities, when accompanied by adequate technology transfer and diffusion, and investments in institutional capacity and complementary policy factors, are key elements of success for a low-carbon inclusive growth agenda in the near future.

Economic Systems and Ecosystems: Interlinkages, Co-evolution or Disparate Movement?

This chapter examines the interlinkages between economic systems and ecosystems. It maintains that the functioning of economic systems has not reflected adequately the role of nature’s categories, ecosystems. While both natural and socio-economic systems can be viewed as complex adaptive systems, there is an urgent need to manage better the disparate movement between them. Two approaches are postulated for doing this. In the first, independently generated scientific knowledge is used in the framework of risk analysis and management to set limits on the domain of economic systems. In the second, economic decision-making is strengthened by attempting to put a value on hitherto unvalued ecosystem services provided to humans. We argue that the two approaches can be used in different contexts and also complement each other in some. However, underlying both is an ethical concern with services and well-being in the future, both of the human and non-human species. Whichever approach we adopt, a stable co-evolution between economic and ecosystems will take place only when such a concern is reached in the form of accepted social norms reflected in policy.

Conclusion: Integrating Sustainable Development and Health Adaptation

This chapter summarises the key understandings developed in the book, in terms of the key challenges and efforts made so far to address these. Effective adaptation in the near term includes meeting the basic public health measures such as clean water, sanitation, vaccination and child health services, just as much as increasing capacity for disaster preparedness. A two pronged strategy is advocated—in terms of what can be done within existing programs and policies to reduce climate related impacts and what new areas deserve focus in an interface between health and climate change to reduce the adverse impacts. The current approaches for achieving sustainable development and the processes for adaptation, concerns of resource availability, information, and guidelines is discussed along with learnings from the historical experiences of the world in addressing health sector challenges in the past. Building institutional capacities, training and knowledge transfer, being inclusive in targeting vulnerable populations, awareness creation and budgeting for resources for these are as crucial as getting in place the right infrastructure. The chapter makes key recommendations for adaptation actions and opportunities in the specific context that developing economies find themselves in today.

Climate Change Adaptation: The International Experience in Health

This chapter presents the current understanding on adaptation needs and its rationale for public health planning. Evolving criteria for guiding adaptation responses and developing an understanding of the economic basis for adaptation decisions are essential for effective adaptation. Historical experiences in adapting to hazards, standard protocols and consensus based international guidelines and learnings from country specific experiences are brought together to frame the domains of an effective adaptation strategy that can address ongoing and new challenges. The role of socioeconomic and technological factors, awareness, political will and institutional capacity in determining the effectiveness of any desired response to vulnerabilities is discussed.

Developing Economy Context for Adaptation Decision-Making

This chapter discusses the wider context of developing economies with particular emphasis on the challenges of sustainable development faced by them. It presents a comparative picture of country profiles in health status, vulnerability to climate sensitive diseases and economic development. The chapter also discusses the important issues in economic decision-making for adaptation, with special reference to concerns and challenges that arise with regard to economic valuation and costing. Challenges in measuring and assessing adaptation in developing economies, available tools and methods, ancillary and externality effects, and distributional issues are considered. The Indian context is used to highlight some of the issues. This is of interest since India represents a country of paradoxes to some extent. Although its economic profile is much better than several others, it continues to face many challenges with regard to poverty alleviation and meeting basic needs including public health.

Introduction: Climate Risks in the Health Sector

This chapter details the structure of the book, and introduces relevant terminology and concepts used in it. The first section describes the scope of the book while the second section presents the conceptual framing in terms of risks to the health sector and adaptation for managing the risks from climate change. It presents the current evidence on climate change and projected risks for the health sector, the association between different climate drivers and prevalence of selected diseases, and concerns of exposure and vulnerability across regions of the world.

Analysing the Interface in Indian Plans and Policies

This chapter analyses the extent and adequacy of the Indian health programmes and the state action plans on climate change in tackling issues of adaptation, in achieving the ultimate outcomes of reducing the burden of disease and building resilience to future adverse impacts on health. The chapter begins with a critical review of the current evidence on the prevalence of what are scientifically established to be climate sensitive illnesses in India including malaria, diarrhoea and dengue among others. Subsequently a critical analysis of the current plans and programmes in terms of the capacity to address these climate related illnesses is conducted, and lessons drawn from the historical experience in tackling illnesses with these programmes. The way forward poses both challenges and offers opportunities as the analysis reveals.

Criticality of the Field: Three Case Studies

The evidence on occurrence of climate sensitive diseases is mounting. The detection and attribution of diseases to climate change has also improved, with epidemiological studies to support such claims. This chapter will specifically consider three important types of climatic events that have had serious consequences for India in the past, and are likely to persist and even increase in the years to come given the threat of climate change. These are heat stress, flood and cyclone related threats posed to the health sector. The three case studies have been done in three different districts of a state in India, which have been experiencing these climate events. The case studies bring out the vulnerabilities that become specific to the Indian situation, taking on the complexity posed by socioeconomic factors that are co-associated with adverse health outcomes. The detailed analysis brings out the major domains of relevance to analyzing the Indian context within which adaptation is to be addressed. The criticality of good research through field work in furthering the understanding of how climate sensitivity can add to lowering both the existing burden of diseases and managing future risks is brought out with illustrations from the case studies.