SPECIAL FEATURE SEAR MODERN ENERGY ACCESS AND HEALTH Jem Porcaro, Sumi Mehta, Matthew Shupler, and Sarah Kissel, UN Foundation; and Michaela Pfeiffer, Carlos Francisco C. Dora, and Heather Adair-Rohani, WHO b    S TAT E O F E N E R GY ACCES S R EPO RT  |  2 0 1 7 Copyright © 2017 International Bank for Reconstruction and Development / THE WORLD BANK Washington DC 20433 Telephone: +1-202-473-1000 Internet: www.worldbank.org This work is a product of the staff of the World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work and accept no responsibility for any consequence of their use. 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Furthermore, the ESMAP Program Manager would appreciate receiving a copy of the publication that uses this publication for its source sent in care of the address above, or to esmap@worldbank.org Cover photo: © Dominic Chavez | World Bank MODERN ENERGY ACCESS AND HEALTH Jem Porcaro, Sumi Mehta, Matthew Shupler, and Sarah Kissel, United Nations Foundation; and Michaela Pfeiffer, Carlos Francisco C. Dora, and Heather Adair-Rohani, World Health Organization INTRODUCTION M odern energy access is an important determinant dying from pregnancy- and childbirth-related complications of human health, as it plays a critical role in the every year (WHO Factsheet, 2014). Anecdotal evidence capabilities of healthcare facilities and aids in the suggests that interventions providing minimal lighting and development of clean and safe household environments. appliance operating services can help to avert many of But in the developing world, thousands of healthcare facil- these life-threatening complications affecting mothers and ities and hundreds of millions of households lack access to newborns during pregnancy (Mills, 2012). When better modern energy services. And the situation will only get lighting and power is introduced, health workers report worse as the energy needs of communities and the health fewer delays in providing life-saving care, more timely sectors in these countries are expected to increase dramat- blood transfusions, and more successful child deliveries, ically in the years ahead. along with improved morale of the patient and health ser- This special feature begins with a look at energy access vice provider (Ibid). In Uganda, the availability of power can and health implications, along with energy access and reli- be a key factor in attracting women to deliver in health facil- ability gaps, at two levels: electrification of healthcare facil- ities, as opposed to at home (Mbonye & Asimwe, 2010). ities and household energy. It then tackles the barriers to Another important facet of energy provision relates to better energy access and reliability, and concludes with the ability to refrigerate vaccines, blood, and other medi- opportunities and options—including decentralized renew- cines. Many diseases (such as pneumonia and measles) able energy, hybrid solar PV/diesel, grid extension, ener- can be prevented through immunizations, yet they still kill gy-efficient medical equipment, a greater availability of approximately 1.7 million children each year (GAVI, 2012), clean energy sources and technologies (such as cleaner mainly in developing countries. A considerable share of cookstoves and fuels). vaccines delivered to these countries is ruined due to poor The paper finds that addressing this unmet need in an cold chain services (WHO, UNICEF, & World Bank, 2009). efficient and timely matter will require decision-makers to In health centers, access to reliable electricity is essential better incorporate health considerations into energy pol- for ensuring the integrity of conditions needed to store icy, and vice-versa. The UN’s 17 Sustainable Development vaccines, blood, and other necessary medicines requiring Goals (SDGs) provide an opportunity to apply a nexus refrigeration. approach to energy and health—building on various link- Energy—and in particular electricity—is required for ages that energy and health have with sustainable devel- the operation of basic amenities, including lighting, venti- opment (including SDG 5 on gender equality, SDG 11 on lation, communications and computer systems. It is also sustainable urban environments, and SDG 13 on climate required for the safe management of medical waste (such action). as non-incineration methods), as well as for the operation of essential medical devices (including emergency surgi- cal, laboratory and diagnostic equipment). Access to clean ENERGY ACCESS AND HEALTH and hot water in healthcare facilities is also generally IMPLICATIONS dependent on access to energy for water pumping and Electrification of healthcare facilities water purification systems. Access to modern energy services plays a vital role in how In addition, there are clear links between access to healthcare facilities function, along with the quality, acces- energy in healthcare facilities and the availability of infor- sibility, and safety of essential health services (Table 1). mation and communication technology (ICT) services. ICT Without reliable power, many of the most basic life-saving is a critical enabler of wider “telemedicine” and “e-health” interventions cannot be undertaken safely, or at all. strategies, which are aimed at allowing health workers in Energy access matters greatly to maternal and child remote areas to consult with better-trained nurses or doc- health, as women and children often bear the brunt of inad- tors elsewhere on the appropriate treatment of urgent equate primary healthcare services (Lale et al., 2007; conditions or the management of health issues for which Taghreed et al, 2005)—with over 289,000 women globally specialized expertise is lacking. The increasing global   1  2    S TAT E O F E L E C T RI CI TY ACCES S R EPO RT  |  2 0 1 7 TABLE 1  Key energy-dependent devices/equipment in healthcare facilities PURPOSE/SERVICE ENABLING ENERGY SERVICE/EQUIPMENT General amenities/ infrastructure Basic amenities and equipment Lighting—clinical/theatre, ward, offices/administrative ICT—mobile phone charger, VHF radio, office appliances (computer, printer, internet router, etc.) Sterilization equipment (dry heat sterilizer or autoclave) Refrigerators, electric fans Cooking, water heating, space heating Potable water, cleaning and sanitation Water pumping (when gravity-fed water not available), purification Health-care waste management Waste autoclave, grinder Service-specific medical services Cold chain Vaccine refrigerator Maternity and child health Suction apparatus, incubator, fetal heart monitor, ultrasound HIV diagnostic capacity ELISA test equipment (washer, reader, incubator) Laboratory and diagnostic equipment Centrifuge, hematology mixer, microscope, blood storage, blood chemistry analyzer, blood glucose meter, X-ray, ECG, CT scan, peak respiratory flow meter Surgical equipment Suction apparatus, anesthesia machine Outpatient services Portable X-ray, oxygen concentrator Source: WHO and the World Bank (2014). Access to Modern Energy Services for Health Facilities in Resource-Constrained Settings, and Practical Action, Poor people’s energy outlook 2013. ubiquity of mobile phones and other similar devices pres- wide range of negative health outcomes that have been ents an opportunity to improve health outcomes—by epidemiologically linked to household air pollution expo- using mobile technologies for education and awareness, sure from cooking with solid fuels able 2). Cooking with diagnostic and treatment support, supply chain manage- solid fuels in a traditional cookstove is also a major source ment, remote data collection and surveillance, remote of ambient air pollution, contributing to as much as 37 per- monitoring, and healthcare worker communication and cent of ambient air pollution in South and South East Asia training. Efficient management of patient records and in 2010 (Smith, K. R., Bruce, N., Balakrishnan, K., Adair-Ro- referrals, as well as collection and reporting of health statis- hani, H., et al., 2014). tics, is also greatly facilitated when computer-based. Women and children in low- and middle-income coun- An initial review of the literature suggests that access to tries (LMICs) are disproportionately affected by lack of energy in health also has some cross-cutting impacts—for access to clean fuels and technologies for household example, on health clinic hours of operation, health service energy generation. Societal norms typically call for costs and retention of health workers. In rural locations far women to be the primary cook of the household, with from national grids, where it may be difficult to attract and their children often close to them or carried on their back retain trained medical staff, reliable electricity can provide during cooking. In addition to being exposed to higher highly valued services such as lighting, cooling, entertain- levels of household air pollution from household energy ment, IT, and communications in staff quarters (WHO & use (Burnett, R. T., et al., 2014), women and children must World Bank, 2014). travel long distances to gather fuel. In several countries, children spend at least 15 hours a week collecting fuel Household energy wood; in some countries, they spend more than 30 hours For households, a lack of access to clean energy and tech- per week (WHO, 2016). Gathering fuel wood can subject nologies for cooking, heating, and lighting leads to house- women and children to an increased risk of injury and vio- hold air pollution at levels that can significantly impact lence. It also displaces valuable time that they could health. These concentrations can be 100 times or more spend in education, income-generating activities, or rest than the emission rates targets set forth in the WHO guide- and leisure. Unsustainable harvesting of wood for cook- lines for indoor air quality: household fuel combustion ing or charcoal production leads to deforestation in cer- (WHO, 2014a). Exposure to household air pollution is esti- tain areas (Smith & Haigler, 2008). Inefficient burning of mated to have contributed to about 4.3 million premature solid fuels emits fine particulates, black carbon, and other deaths globally in 2012 (WHO & GHO, 2015). There is a short-lived climate pollutants, and thus contributes to cli- mate change. MODERN ENERGY ACCESS AND H E A LTH   3  TABLE 2  Common diseases linked to household air pollution exposure GLOBAL DEATHS BREAKDOWN OF DEATHS ATTRIBUTABLE NONCOMMUNICABLE DISEASE CAUSED BY HAP IN 2012 TO HAP, BY DISEASE IN 2012 Chronic Obstructive Pulmonary Disease 905,856 21.3% Lung Cancer 271,041 6.4% Stroke 1,458,412 34.2% Ischemic Heart Disease 1,095,014 25.7% Lower respiratory infections 531,190 12.5% Source: WHO Regions (2012). Household air pollution burden of disease. Note: HAP stands for household air pollution ENERGY ACCESS AND RELIABILITY GAPS FIGURE 1 High electricity deficits for healthcare facilities Electrification of healthcare facilities Percent of healthcare facilities lacking electricity Despite the critical role energy plays in enabling health ser- Uganda (2007) vices, there is a dearth of power in health facilities in devel- oping countries, according to existing (albeit sparse) data. Tanzania (2006) For example, a recent analysis of available data on access Guyana (2004) to energy in healthcare facilities1 in 11 sub-Saharan coun- Sierra Leone (2012) tries shows that on average more than 25 percent of the Ghana (2002) health facilities lack access to electricity (Adair-Rohani et al., 2013). The situation is particularly problematic in pri- Nigeria (2011) mary healthcare facilities, especially those serving rural and Kenya (2010) remote populations, the study notes, with access for rural Zambia (2005) clinics in some of these countries dropping below 25 per- cent—although the problem is not limited to Africa. Rwanda (2007) Another study (WHO and World Bank, 2014) shows that Ethiopia (2008) some developing countries (like Uganda and Tanzania) report that as many as 50 percent or more health facilities 0 10 20 30 40 50 60 lack access to electricity (Figure 1). Source: Adair-Rohani et al., 2013 Ensuring a reliable supply of energy is another chal- lenge, particularly as one moves up from primary care facil- ities to district and referral hospital levels. Even when health facilities are connected to the grid, many suffer fre- Household energy quent power outages. On average, only 28 percent of all At the household level, the share of the population without facilities with electricity access (Adair-Rohani et al., 2013) access to clean cooking fuels varies greatly by region— report reliable access to electricity, with Sierra Leone as low with the majority of individuals using polluting fuels for as 14 percent. This matters greatly, given that power qual- cooking in sub-Saharan Africa and South Asia (WHO, ity disturbances such as surges and frequency fluctuations 2016). Several LMICs in Asia are expected to see an can damage or destroy medical devices. WHO estimates increase in clean energy access by 2030, while the situa- that nearly 70 percent of medical devices used in develop- tion will worsen in Sub-Saharan Africa, where the number ing countries fail (WHO, 2010), with poor power quality a of people without clean cooking facilities is expected to major contributing factor. rise by about 20 percent (IEA, 2012). The source of power used in healthcare facilities in The specific metric used by WHO to evaluate progress developing countries varies significantly, with multiple toward SDG 7 is the “percentage of population with pri- sources often being drawn on at a single facility (including mary reliance on clean fuels and technologies at the grid power, diesel generators, and renewable energy sys- household level” (WHO, 2015). The categories of “clean” tems). In Uganda, 15 percent of hospitals and 2 percent of and “polluting” fuels and technologies were added in other facilities use a combination of grid-connected and 2015 (WHO, 2014a), setting a scientific basis for interven- solar sources; in Sierra Leone, up to 36 percent of all health- tions and serving as a step up from the previous evaluation care facilities use power from a solar energy source, com- of household energy, which only considered the share of pared to 25 percent using a generator and only 13 percent the population using “solid fuels.” using grid electricity (Adair-Rohani et al., 2013). Adding The 2015 Report of the Global Tracking Framework further complexity, different energy sources are used for shows that the annual growth of global access to non-solid different purposes, ranging from primary power to back-up fuels from 2010–12 was –0.1 percent, similar to that of power for only a few hours a day or for emergency services. 2000–10. This is significantly below the target energy Other energy sources used in healthcare facilities may access growth rate of 1.7 percent to reach the SDG of uni- include kerosene or gas to power vaccine refrigerators. versal energy access by 2030. If the current rate of house- 4    S TAT E O F E L E C T RI CI TY ACCES S R EPO RT  |  2 0 1 7 hold energy access continues, it is projected that by 2030, but a lack of operating and maintenance funds can impair only 72 percent of the global population will have access to the long-term sustainability of power systems, often ren- modern energy services for clean cooking (IEA & World dering the equipment unusable. More innovative financing Bank, 2015). As of 2012, primary access to non-solid fuels instruments are needed. among the global population rose slightly to 59 percent from 58 percent in 2010, with about 125 million people Weak local energy sector and service infrastructure. (mostly in urban areas) gaining first-time access (Ibid). Many countries lack an off-grid sector to meet the energy Other survey data confirm that the type of fuel used varies needs of health facilities, starting with the design and drastically by urban and rural settings, with about 20 per- installation of systems in the field. Common problems cent of urban households using primarily solid fuels in tra- relating to system design and installations are: lack of data, ditional cookstoves, well below the 80 percent in rural poor system sizing, and poor installation (McCarney et al., areas (WHO, 2016a). 2013). Designers and field technicians must receive regular training and information to create a supply of qualified energy providers, and they should be taught best practices BARRIERS TO BETTER ENERGY ACCESS of energy use in medical facilities. Reliable supply chains AND RELIABILITY are important not only for the installation of equipment but Electrification of health facilities also for ensuring effective maintenance. There are several barriers to electrifying health facilities. The key barriers fall into the following categories: Lack of maintenance. Off-grid technologies often fail pre- maturely due to lack of maintenance, leading to the per- Weak enabling environments. Increasing electrification ception that renewable technologies are too unreliable to in health facilities relies on a strong national enabling serve the needs of communities. Maintenance challenges framework—including policies, regulations, and technical include: failure to properly care for the systems (such as standards—which is lacking in many countries. Nonethe- regular cleaning and topping up battery cells with distilled less, in many health sectors, energy access is not priori- water); lack of local qualified technicians; lack of funding tized within efforts to strengthen health systems that are for spare parts; and unclear ownership. To achieve long- aimed at better planning and better service delivery. term operational sustainability, it is critical to step up main- Although import duties and subsidies for fossil fuel power tenance plans and capacity building, and adopt innovative can make it difficult for off-grid technologies to compete, technologies like remote-monitoring systems. they remain in place in many countries. Enhanced Rural health clinics in particular face many of these inter-sectorial dialogue is necessary in order to ensure challenges, along with other challenges specific to their that health sector energy needs are reflected in wider settings. For example, in many areas in sub-Saharan national energy planning processes. Africa and south Asia, rural electrification rates cannot keep up with population growth and the power demands Lack of awareness and information. Little attention has that come with it. Additionally, rural healthcare facilities been given to the central role that energy access plays in and the communities they serve are often very remote influencing the quality, availability, and safety of primary and characterized by limited surrounding infrastructure and essential maternal and child health services. Rather, and low energy demand. As a result, they are less attrac- energy is largely treated merely as a facility, operations, tive to traditional energy service providers (such as utili- and infrastructure issue. Healthcare and other actors need ties) and lack capital to fund energy systems. Plus, a lack to be made more aware of the interconnectedness of these of institutional capacity and low numbers of trained indi- linkages and equipped with information, tools, and guid- viduals to perform maintenance make the issue worse, as ance on how to monitor them and identify gaps. they lead to systems that provide unreliable power with frequent power outages, even where clinics are con- Insufficient human capacity and institutional support nected to a grid. structures. Health care facilities often lack adequate capacity to manage and service power systems. Health Household energy clinic administrators need to be equipped with the tools At the household level, several barriers stand out, which and knowledge to improve their systems in order to ensure vary in importance depending on the location and pre- sustainable financial and operational maintenance of dominant cooking technology in place: energy systems and implement good practices in obtain- ing and using electronic medical devices (WHO & World User acceptability. Individuals experience difficulty adjust- Bank, 2014). ing to an improved cookstove for multiple reasons, includ- ing the convenience and durability of the cookstove Affordability and lack of financing options. Even though (Ruiz-Mercado, I., et al., 2011). There are also lifestyle bar- the cost of power solutions has decreased, affordability riers, as cooking is embedded in the culture of households. remains a barrier to the adoption of power by healthcare Also, households may prefer the taste of food cooked on facilities—especially public health facilities in developing traditional cookstoves. Thus, behavior change communi- countries that rely on scarce government funding to sup- cation must be incorporated into interventions and the port their operations. Governments and donors have cook’s preferences incorporated into the design of new begun providing capital for health facility electrification, stove technologies. MODERN ENERGY ACCESS AND H E A LTH   5  Lack of information and gender norms. Households lack approach, centered on a holistic evaluation of needs, information on how the use of dirty fuels and technologies including gender—rather than a piecemeal approach that for cooking, heating, and lighting can harm health. In other can lead to inefficiencies in design, unmet needs, and, cases, even knowledgeable women may not receive per- often, early system failure. Moreover, the need to act is mission from their husbands to purchase a clean stove pressing, given that the energy needs of the health sectors (IFC, 2014): A willingness to pay often must come from in LMICs are expected to increase dramatically. For exam- both the male and female head of household. ple, the need for cold storage space for vaccines is expected to rise eightfold or more in coming decades Undervaluation of fuel and time saving. A saving on fuel (PATH & WHO, 2008), and the growing need to prevent or amount (and therefore cost to the household) is one of the fight non-communicable diseases requires complex inter- most appreciated aspects of an improved cookstove by ventions that will drive additional energy requirements participants (WHO, 2016b), although this is often not (WHO & World Bank, 2014). Possible solutions include the incorporated in the decision-making process. Thus, stove following: developers must consider time associated with fuel pro- cessing and/or cleaning the stove or chimney when trying Decentralized renewable energy. This approach can be to decrease fuel consumption. a first step toward enhanced energy provision, either by providing backup for grid-connected facilities where exist- Socio-economic status. Those with the lowest income lev- ing supply is unstable or erratic, or as a primary energy els are generally experiencing the worst health and time source for rural health facilities that are far from the grid burdens associated with cooking with polluting fuels and and not prioritized for connection in the near future. In the technologies. These households are commonly suscepti- case of solar PV, module prices have dropped considerably ble to multiple other health problems, with few resources over the past five years, battery storage capacity has to deal with them. Clean energy access serves as a crucial increased and is set to improve further in the coming years, component that can lift families out of poverty by increas- and remote monitoring capabilities are making it easier to ing the availability and affordability of resources that can more effectively manage the energy requirements of mul- improve health, such as clean cooking stoves and fuels. tiple facilities. Also, while the up-front capital cost of a solar system may be higher than that of a diesel generator, the Lack of financing options. While the cost of a cookstove cost over the system’s life is generally less thanks to lower may be subsidized to an affordable price, or a cookstove operating costs—reflecting the lack of need to purchase may be provided to participants free of charge for use diesel fuel (USAID, Powering Health Data). This option can during an intervention study, households may not be able be particularly relevant in rural and remote areas, where to afford fuel and/or maintenance costs over time and the ability to source diesel can be difficult, extremely revert back to using their traditional stove. Therefore, costs costly, and may not be adequately covered by health clinic associated with repairs and fuel prices post-intervention budgets. need to be accounted for to make the clean stoves and fuels financially competitive with traditional cookstoves. Hybrid solar PV/diesel. This combination may be appro- priate where (i) load requirements are too high for solar PV Supply and distribution. Efficient supply chains can lower alone, and the battery capacity is not large enough to the costs of producing a clean cooking technology, directly cope with the associated load; or (ii) there are strong sea- impacting affordability for the user. In addition to the initial sonal variations in the solar insolation. It may also be effec- production of an improved cookstove, the market must be tive when uninterrupted power is needed for an operating sustained by offering replacement parts and services to room, and large loads are required for heating or cooling users. Stove entrepreneurs must develop a flexible busi- devices and x-ray machines—with the solar system provid- ness plan that can handle an initial low demand of stoves ing the main source of power and the diesel generator among the target population (WHO, 2016b). ensuring that back-up power is available. In these situa- These barriers often result in “stove-fuel stacking”— tions, “triaging” power requirements is critical, based on that is, individuals primarily using their clean-fueled stove clear priorities and directives regarding power usage. but also using their traditional stoves and other polluting fuels for cooking, heating, and lighting. To maximize the Grid extension. This approach is attractive if the grid is health benefit of a clean cooking technology, complete close enough to justify the extension and connection costs. termination of the traditional cookstove and polluting fuels However, a grid connection alone does not ensure access must occur (Johnson & Chiang, 2015, WHO 2014a). to reliable power, as many developing countries (particu- larly those in sub-Saharan Africa and South Asia) suffer from chronic power shortages owing to inadequate gener- OPPORTUNITIES AND OPTIONS ation capacity. Thus, health facilities are often forced to Electrification of healthcare facilities invest in backup power sources or cope with inadequate The international community’s adoption of the SDGs supply opens a major opportunity for the health sector to improve access to, and the quality, of health services—especially for Energy-efficient medical equipment. For procedures maternal, newborn, and child health services. What is such as ultrasounds or blood oxygen measurements, new needed is a more comprehensive and systems-based portable low-energy direct-current medical devices can be 6    S TAT E O F E L E C T RI CI TY ACCES S R EPO RT  |  2 0 1 7 operated from solar PV panels and work well in ener- Once a stove has been designed, innovative monitor- gy-constrained environments. LED-illuminated micro- ing and evaluation (M&E) is required to ensure acceptable scopes and vaccine refrigerators are able to store solar product performance. To that end, investments are being energy in freezer packs in place of batteries, thereby made to establish globally accepted standards for evaluat- avoiding extra costs for battery maintenance and replace- ing cookstove technology. Besides the new WHO guide- ment. lines for indoor air quality: household fuel combustion Governments, donors, and, where possible, the private (2014a), global standards are being developed by the sector should consider prioritizing health facility electrifi- International Organization for Standardization (ISO). So far, cation as a key development issue in order to improve the the ISO has issued International Workshop Agreement delivery of energy-dependent health services and to help (IWA) guidelines, which rate cookstove performance on reduce the vulnerability of communities. Coordination four factors—efficiency, indoor emissions, total emissions, across both the energy and health sectors is necessary so and safety—across 5 tiers (0 being lowest-performing and that the needs of health facilities are met in a sustainable 4 being highest-performing), with boundaries defined by and long-lasting manner. Deployment should always quantitative values determined by laboratory testing. For account for the lifetime of the solution set, and mecha- example, shifting to better performing stoves and fuels nisms should be set in place for appropriate long-term can dramatically lower the risk for childhood pneumonia. maintenance and parts replacement. Additionally, the The ISO is currently assessing whether the IWA tiers of per- improving ability to provide certain diagnostics capabili- formance will be used in the final standard. ties using cell phone apps and other mobile-en-abled At the same time, policymakers must also consider technology should be explored to help ensure the most health and climate co-benefits in cookstove M&E, as the effective utilization of limited power availability in the clinic most environmentally sustainable cookstoves and fuels setting. may not maximize health benefits: There are varying con- centrations of greenhouse gases and short-lived climate Household energy pollutants emitted from different cooking technologies, At the household level, the key is pursuing policies, pro- which results in cooking technologies having different cli- grams, and interventions that increase the availability of mate-altering impacts (Ramanathan, V., & Carmichael, G., clean energy sources and technologies. For cookstove 2008). For that reason, the same IWA tiers for evaluating producers, markets are being analyzed at the regional health are also available for assessing climate impact. For level to allow for a diversity of technologies that can satisfy example, as Figure 3 shows, while a charcoal stove may the needs of individuals with different cultural and gender score higher on health impact than a Tier 1 advanced bio- norms. Local clean cookstove businesses are the most mass, portable ‘rocket’ stove, a charcoal stove remains in likely to be aware of local community needs and local mar- Tier 0 because it scores very poorly on climate impact. ket barriers. FIGURE 3  Picking the best stove for both health and the climate Directional only Green 0 1 2 3 4 Solar Biogas Natural draft gasifier LPG Ethanol Fan gasifier Electric Natural draft gasifier Kerosene Built-in rocket Climate impact Basic efficient wood Portable rocket High-range charcoal 3 stone fire Mid-range charcoal Vented coal stove Basic charcoal ICS Coal traditional Polluting Charcoal traditional Unhealthy Health impact Clean Source: Putti, V.R., Tsan, M., Mehta, S., Kammila, S. 2015. The State of the Global Clean and Improved Cooking Sector. Note: The four ISO tiers are evaluated according to stove efficiency/fuel use, total emissions, indoor emissions, and safety, with Tier 0 being the lowest performing, and Tier 4 being the highest performing. MODERN ENERGY ACCESS AND H E A LTH   7  FIGURE 4 Trends in uptake of clean and/or efficient cookstoves and fuels (Number of cookstoves distributed to households in LMICs from 2010–2014) 25m Stoves* distributed (million) 20m 20m 15m 14.4m 10m 8.2m 5m 3.6m 12.1m 2.5m 5.2m 6.5m 0m 1.4m 1.9m 2010 2011 2012 2013 2014 Total stoves* distributed per year Clean and/or efficient **Household stove equivalents estimated from fuel volumes, starting in 2014 Source: 2014 Results Report. Global Alliance for Clean Cookstoves How much progress is being made in scaling up clean decisions regarding fuels and cooking technologies and cooking technologies and fuels? The latest Results Report how these perspectives influence purchase decisions from the Global Alliance for Clean Cookstoves (Alliance, (Pachauri & Rao, 2013; WHO, 2016a). For example, a 2015) shows that over 12 million clean and/or efficient recent study in Bangladesh found that women had a cooking technologies were distributed in 2014— almost stronger desire for improved cookstoves than men, but double that of 2013 (Figure 4). Over half of the cleaner lacked the authority to make the decision to purchase cooking technologies distributed in 2014 were estimated one (Miller & Mobarak, 2013). to have a Tier 2, 3, or 4 rating for indoor emissions or fuel efficiency, a tenfold increase from 2013. Likewise, reported clean fuel production increased 100-fold, and CONCLUSION reported fuel distribution increased 200-fold between The tremendous health improvements that can result from 2013 and 2014. universal energy access should not be overlooked. Achiev- Since the Alliance’s formation in 2010, more than 50 ing universal energy access can improve human health by million stoves and fuels have been distributed, which sets strengthening the capabilities of healthcare facilities and the Alliance and its partners on track to reach their goal of enhancing the safety of household environments. Such 100 million households adopting clean and efficient cook- health gains will be realized when health considerations stoves and fuels by 2020. The Alliance’s Clean Cooking are incorporated into the planning and implementation of Catalog—san online global database of cookstoves, fuels, energy investments, and vice versa. Encouragingly, a specifications, prices, manufacturers, and third-party vali- growing number of organizations—including the WHO, dated performance testing—provides public information Global Alliance for Clean Cookstoves, Sustainable Energy on the characteristics and relative performance of various for All, and United Nations Foundation—are working with stove and fuel innovations, reflecting the increased tech- governments to raise awareness about the inextricable nologic innovation that has occurred in the household links between energy and health. As these organizations cooking sector. move to identify and diminish research gaps, develop To continue scaling up clean technologies, interven- country-capacity for implementation, and overcome barri- tions and policies will need to consider contextual fac- ers associated with uptake and sustained energy use at the tors involved with energy purchasing at the household community and household level, they can simultaneously level. Household energy research is now focused on catalyze action needed to effectively and efficiently examining different male and female behaviors and address multiple SDG goals. NOTE . 1. The analysis included all health facilities in each country and grouped them as “hospital” and “other facilities”. 8    S TAT E O F E L E C T RI CI TY ACCES S R EPO RT  |  2 0 1 7 REFERENCES Adair-Rohani, H., Zukor, K., Bonjour, S., Wilburn, S., Kuesel, Washington, DC. https://openknowledge.worldbank.org/ A., Hebert, R., et al. (2013). Limited electricity access in handle/10986/21878. health facilities of sub-Saharan Africa: a systematic review Ramanathan, V., & Carmichael, G. (2008). Global and regional of data on electricity access, sources, and reliability. climate changes due to black carbon. Global Health Science Practice. 2013;1(2):249-261. http:// Nature Geoscience, 1(4), 221–227. www.ghspjournal.org/content/1/2/249.full Ruiz-Mercado, I., Masera, O., Zamora, H., & Smith, K. R. Burnett, R. 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