Candidate No.

100822 Module Code: 909N1

POLICY BRIEFING

APRIL 2013

Heartily cleaning the hearth: Seeking an integrated approach to IAP

There is an urgent need to address the issue of Indoor Air Pollution (IAP) in India with heightened political will and commitment. It causes several lung, pulmonary, cardio-vascular and respiratory illnesses. It caused 1.3 million deaths in the year 20101, and ought to be recognised as a public health emergency and be given due attention. It is estimated that around 80% of women in India are affected by Indoor air pollution2. The disproportional burden of the disease on women and children has severe macro and micro economic and social repercussions. A multi-sectoral and integrated intervention that accounts for and combats social and economic enabling factors and understands user preferences is needed to deal with Indoor Air Pollution. The intervention must also consider partnerships with private social enterprises and non governmental organisations who are willing to build low cost stoves. Reviewing some of the measures taken by India with regards to Indoor Air Pollution, this policy brief will argue that past and existing interventions have not been adequate in dealing with the issue. It makes a case for holistic, actionable interventions ranging from the use of clean fuels and modern stoves and improving ventilation to rigorous monitoring and behavioural change communication. This brief is presented to The Ministry of Health and Family Welfare ; The Ministry of Women and Child Development, The Ministry of New and Renewable Energy and The Ministry of Rural Development, and argues for the need of inter-departmental co-operation in tackling IAP.

KEY MESSAGES:

Image courtesy: www.yale.edu

Integrated, inter-departmental, beneficiary-centric approach Distribution of modern stoves to BPL families with private sector partnership Subsidising/ incentivising energy fuels for BPL families Facilitating public education and awareness targeting women Setting up of SHGs among women for experience sharing

28%

72%

Data courtesy www.shellfoundation.org

1

and 2 were mentioned in a Hindustan Times report, dated February 25th, 2013.

Candidate No. 100822 Module Code: 909N1

IAP and its magnitude

Indoor air pollution (IAP) is caused by traditional stoves and reliance on unprocessed solid fuels such as biomass. Its effects are felt manifold in small, congested dwellings due to prolonged exposure to the pollutants, which are fine particles and have no trouble in easily penetrating the lungs. According to the National Health Family Survey 2005-2006, over 91% of households in rural India (and about 71% of total households) use biomass (in the form of cow dung, wood and agricultural residue) as their cooking fuel. Burning these fuels within the confines of a house produces high volumes of toxic pollutants. The United States Environmental Protection Agency has set the accepted level for IAP at 150 g/ cu.m, whereas in India the mean level in household can exceed 440g/ cu.m3.

It is estimated that India accounts for 28% of all global deaths due to IAP4
The increase of many severe illnesses in India, viz, acute respiratory infections (ARIs), pneumonia, lung cancers, asthma, tuberculosis, cardiovascular diseases, bronchitis, vision related diseases such as cataract and adverse effects on pre-natal and post natal health are attributed to Indoor Air Pollution (Smith, 2000). Due to traditional gender roles in India, women and children (under the age of 5) end up bearing the brunt of the burden of Indoor Air Pollution caused morbidities, as they spend most of their time near the hearth in the kitchen. Morbidity Patterns caused by constant exposure to IAP: Demographic Children <5 years Pregnant women and new mothers Adults >30 Health Threat ARIs, bronchitis, pneumonia Low birth weight, ischaemic heart disease, nasopharyngeal and laryngeal cancers, still borns COPDs, lung cancer, tuberculosis, cataract, asthma

Derived from National Burden of disease in India from indoor air pollution (Smith, 2000)

Indoor Air Pollution takes a very big toll on the micro economic situation as the affected tend to hail from Below Poverty line (BPL) families in rural India. Its costs may include hospitalisation, medicines, loss of wages and visits to the doctor 5. The opportunity cost of women, who may lose several months and years to illnesses, when they could have been working to supplement the income of a BPL family, must also be kept in mind. Mitigation measures such as alternate fuels and modern stoves may also prove to be too expensive for poor families.

The Story so far

Despite several interventions and measures by both the government as well as the private sector, the situation in India with regards to IAP has largely been status quo.

The total number of deaths in India caused by IAP in 2003 was 407,100; whereas in 2010, the figure increased to a staggering 1.3 million.6
Reviewing the governmental interventions that have been implemented to combat Indoor Air Pollution, it can be seen broadly that most of them have relied more on commercialisation as against the welfare and subsidy approach (Hanbar and Karve, 2002). And while there has been an overwhelming focus on research, development and innovation, less attention has been diverted to community mobilisation, behaviour change communication, working on strengthening credit system for household expenses and subsidising clean fuels and working on a distribution/ subsidy system for modern stoves. Moreover, both private and public interventions have been market driven which has been a failure in terms of reaching the intended target populace. This overly profit based strategy has not worked as the average per capita monthly expenditure on cooking fuels in rural areas has been found to be as low as Rs.60. (Dalberg, 2013). While the government has subsidies on cooking fuels such as kerosene and LPG, studies suggest that these are often misused by way of illegal diversions. (Rajarathnam, -) Many of these governmental interventions that do claim to distribute stoves and subsidise fuels tend to be funded and implemented by two different ministries (UNICEF, 2011) thereby creating a lack of cohesion and cooperation among partaking departments. National Programme on Improved Cookstoves (NPIC) was Indias longest running and biggest intervention against IAP. Implemented across 23 states and 5 union territories for 18 years, its aim was to install improved/ modern cook stoves to approximately 120 million households across the country. The programme was started by the Ministry of Non-Conventional Energy Resources. The stoves cost between Rs. 100 and Rs. 300, but was heavily subsidised by direct cash. Looking back at the impact of the programme, it succeeded in installing 28 million improved stoves (Ramana and Kishore, 2002). However, sustained usage and actual effects on health improvement and whether there was a reduction of IAP caused deaths are questionable. One of the biggest critiques of this programme was that the stoves were not of top quality and became unusable over a period of time. (Sinha, 2002) There were also issues with its design as many of the stoves could not withstand the heat required for cooking or were not big enough to accommodate the cooking pots. The huge government subsidy suppressed social entrepreneurs who despite building better quality stoves could not compete with the price that the government offered. (Dalberg, 2013)

3 4

Balakrishnan, K., et al, pp.4 From www.shellfoundation.org 5 Chandramohan, B.P., et al 6 Hindustan Times report, dated February 25th, 2013.

Candidate No. 100822 Module Code: 909N1

In Conclusion..

Therefore, it is apparent that while isolated interventions do help to mitigate some health effects of IAP, a completely successful intervention needs an integrated inter-departmental approach that is beneficiary driven, and backed properly by thorough community programmes that work on behavioural change campaigns, participatory learning, and discussion cafes on safe cooking

Policy Recommendations and the way forward

Distribute modern stoves to Below Poverty Line Households in Rural Areas:

Duflo et al in their 2008 study in Orissa, India found that cooking with a clean stove is associated with better health. All BPL households (currently including all households earning below Rs. 22.42 a day in rural areas) must be entitled to receive a working modern stove. Private players must be invited to give their designs, and priority must be given to designs that ensure longevity of the stove. Use user input by conducting focus group discussions to understand cooking trends and incorporate these suggestions into the design of the cooking stove.
Subsidise/ incentivise clean energy fuels for Below Poverty Line Households:

While kerosene and LPG are already available at heavily subsidised rates in India, there needs to be more focus and attention in ensuring that these fuels at the subsidised prices reach the poorest and most deserving. Use targeted subsidies for clean energy fuels in selected pockets in impoverished areas. As a World Bank Report (Undated) explains, misdirected subsidies caused half the subsidised kerosene to be diverted to the black market in 1999-2000. Direct cash transfers to incentivise usage of clean fuels may be considered at a pan-national level.
Facilitate public education and awareness:

Strategic Behavioural change communication targeting women needs to supplement distribution and installation of stoves. There needs to be a conscious effort to get the point across that there is a strong link between morbidity, mortality and indoor pollution. Apparent health benefits on the use of clean fuels and modern stoves need to be explained with the help of film and video. Cook stove demonstration and installation need to be done at every household that is eligible. Other points also need to be emphasised through community meetings: windows/ chimneys for better ventilation and periodic health tests to keep a tab on blood pressure and lung health.
Set up Self Help Groups among women for experience sharing:

Most interventions reviewed here reported the lack of monitoring and follow up (Sinha, 2002) (Kishore and Ramana, 2002), resulting in several stoves. Monitoring and follow-up can be made more community based and participatory with the help of Self Help Groups consisting of women. Facilitate sessions of experience sharing, so that women can discuss usage of cookers and clean fuels and how it helped improve their health. The Ministry of Women and Child Development has extensive experience in curating SHGs and pre-existing groups can be mobilised for this purpose, with The Ministry of New and Renewable Energy chipping in with expert knowledge.

Further reading
Kishore, V.V.N. and Ramana P.V. (2002) Improved cookstoves in rural India: how improved are they? A critique of the perceive d benets from the National Programme on Improved Chulhas (NPIC), Energy 27.1: 47-63, http://www.whrc.org/policy/pdf/India/Kishore%20and%20Ramana.% 202002.pdf (accessed 18 April 2013) Sinha, B. (2002) The Indian stove programme: an insiders view the role of society, politics, economics and education, Boiling Point 48: 23-26, http://practicalaction.org/docs/energy/docs48/bp48_pp23-26.pdf (accessed 18 April 2013) Srivastava, R., Misra, P., Krishnan, A., Mohan, P., van den Hombergh, H. and Sehgal, M. (2011)Indoor Air Pollution: A Case f or Change, The Energy and Resources Institute: New Delhi, http://www.unicef.org/india/Policy_Brief_1-Indoor_air_pollution.pdf (accessed 18 April 2013)

References
Balakrishnan, K., Mehta, S., Kumar, Priti., Ramaswamy, P., Sambandam, S., Kumar, K. S., Smith, K. R. (2004) Indoor Air Pollu tion: Associated with Household Fuel Use in India: An exposure assessment and modelling exercise in rural districts of Andhra Pradesh, India, Washington D.C: World Bank, http://ehs.sph.berkeley.edu/krsmith/publications/ESMAP%20report.pdf (Accessed 16 April 2013) Chandramohan, B.P., Villalan, T. K. S., Karthikeyan, S. ( 2010) The Economic Cost of Health Problems due to Indoor Air Pollu tion at the Household Level in Tamil Nadu, paper prepared for the Fifth Annual Himalayan Policy Research Conference, University of Wisconsin, 14 October Chetan, C. (2013) Indoor Air Pollution kills 1.3 mn Indians, Hindustan Times, 25 February, http://www.hindustantimes.com/India-news/NewDelhi/ Indoor-air-pollution-kills-1-3mn-Indians/Article1-1016917.aspx (accessed 16 April 2013) Dalberg Global Development Advisors (2013) Indian Cookstoves and Fuels Market Assessment, Washington D. C: Dalberg, http:// www.cleancookstoves.org/resources_files/india-cookstove-and-fuels-market-assessment.pdf (accessed 16 April 2013) Duflo, E., Greenstone, M and Hanna, R (2008) Cooking Stoves, Indoor Air Pollution and Respiratory Health in Rural Orissa, Economic and Political Weekly 43.32: 71-76, http://web.mit.edu/ceepr/www/publications/reprints/Reprint_205_WC.pdf (accessed 16 April 2013) Hanbar, R. D. and Karve, P. (2002) National Programme on Improved Chulha (NPIC) of the Government of India: an overview, Energy for Sustainable Development 6.2: 49-55, http://www.sciencedirect.com/science? _ob=MiamiImageURL&_cid=277423&_user=128860&_pii=S0973082608603130&_check=y&_origin=article&_zone=toolbar&_coverDate=2002Jun-30&view=c&originContentFamily=serial&wchp=dGLzVlS-zSkWz&md5=2a18ee9609e647d3bbe1b786ef6c80f0&pid=1-s2.0S0973082608603130-main.pdf (Accessed 16 April 2013) International Institute for Population Sciences and Macro International (2007) National Family Health Survey (NFHS-3), 2005-06, India: Key Findings. Mumbai: IIPS, http://www.measuredhs.com/pubs/pdf/SR128/SR128.pdf (accessed 16 April 2013)

Candidate No. 100822 Module Code: 909N1

References

Kishore, A (2013) Empowering Women to Reduce Indoor Air Pollution in India, India in Transition, http://casi.sas.upenn.edu/iit/kishore (accessed 16 April 2013) Kishore, V.V.N. and Ramana P.V. (2002) Improved cookstoves in rural India: how improved are they? A critique of the perceive d benets from the National Programme on Improved Chulhas (NPIC), Energy 27.1: 47-63, http://www.whrc.org/policy/pdf/India/Kishore%20and%20Ramana.% 202002.pdf (accessed 18 April 2013) Pope, D. P., Mishra, V., Thompson, L., Siddiqui, A. R., Rehfuess, E. A., Weber, M., Bruce, N. G. (2010) Risk of Low Birth W eight and Stillbirth Associated With Indoor Air Pollution From Solid Fuel Use in Developing Countries, Epidemiologic Reviews 32 (1): 70-81, http:// epirev.oxfordjournals.org/content/32/1/70.long (accessed 16 April 2013) Rajarathnam, U., () Policy Gaps in addressing Household energy, Indoor air pollution and Health Issues in India, unpublished , http%3A%2F% 2Fwww.saee.ethz.ch%2Fevents%2Fcleancooking%2FUma_Paper_for_Istanbul_conference.doc&ei=O26BUfvSMqb40gWioG4DQ&usg=AFQjCNHn_nCjh3urBCYTNykoG3Czeqi76w&sig2=bno1BMbcwdxlsAKiaHzL5A&bvm=bv.45921128,d.d2k (Accessed 16 April 2013) Shell Foundation (2009) India IAP Health Facts and Figures, http://www.shellfoundation.org/pages/core_lines.php? p=corelines_inside_content&page=breathing&newsID=351 (accessed 16 April 2013) Sinha, B. (2002) The Indian stove programme: an insiders view the role of society, politics, economics and education, Boiling Point 48: 23-26, http://practicalaction.org/docs/energy/docs48/bp48_pp23-26.pdf (accessed 18 April 2013) Smith, R. K. (2000) National burden of disease in India from indoor air pollution, Proceedings of the National Academy of Sciences of the United States of America 97.24: 13286 13293, http://www.pnas.org/content/97/24/13286.long (accessed 16 April 2013) Srivastava, R., Misra, P., Krishnan, A., Mohan, P., van den Hombergh, H. and Sehgal, M. (2011)Indoor Air Pollution: A Case f or Change, The Energy and Resources Institute: New Delhi, http://www.unicef.org/india/Policy_Brief_1-Indoor_air_pollution.pdf (accessed 18 April 2013) World Bank () Access of the Poor to Clean Household fuels in India, Washington D.C: World Bank, http://siteresources.worldba nk.org/ INDIAEXTN/Resources/Reports-Publications/Access-Of-Poor/FullReport.pdf (Accessed 18 April 2013)