Before Coronavirus struck in March 2020, Kenya was pioneering a radical new approach to reducing deaths from household air pollution by training community health workers to inform people about the dangers of traditional polluting fuels and encourage them to switch to cleaner alternatives. The country is aiming for most homes to be using clean energy by 2030, but the health workers’ efforts may be frustrated if policies and investment do not ensure availability and affordability of fuels such as LPG and electricity. With governments grappling with plans for recovery as countries emerge from the pandemic, the International Energy Agency has published ‘Sustainable Recovery’, a three year road map for energy-sector financing that promises economic growth, new employment and sustainable reductions in climate warming emissions. The proposals include investment of US$ 150 billion in electrification and clean cooking fuels for households in low income countries, which could help to achieve Sustainable Development Goal 7 for universal access to clean energy by 2030 in Kenya and across Africa.
Nancy Chebichii, one of 40 community health volunteers from Uasin Gishu county in Kenya, recently completed three days of training on how to reduce household air pollution. She energetically conveys the enthusiasm with which the course was received, speaking on behalf of the whole group of which she served as chair during the training.
“We know our own situations are as bad as our villages, so everyone is really thinking, hey, what plans do I make? All of us are so energised to start with ourselves, and of course our neighbours are our friends and relatives, so when you are changing, your neighbour is curious, asking why are you doing that? And you will say: ‘hey, let me give you the story’.”
Her fellow community health worker Lynn Lelan concurs: “We wish to be role models to fellow community members. There is a phrase we usually say – ‘When you have been found, go and find others’.”
Energy in the home should bring multiple benefits, and for the developed world that is generally the case. But in low-income countries including most of Africa, the way energy is used for cooking, lighting and heating is a major contributor to ill-health, injury, and persisting poverty. It also contributes to the loss of forests and climate-warming emissions. Without concerted efforts by countries and the international community, this will remain so for the foreseeable future.
Household air pollution: still a major public health challenge
Globally, three billion people rely on inefficient stoves burning wood, charcoal and kerosene. The resulting air pollution in and around the home causes around 3 million premature deaths per year from pneumonia, chronic lung disease, cardiovascular disease, stroke and lung cancer. It also increases the risk of low birth weight and blindness through cataract. Burns from open fires and wood stoves are common, as are poisonings of children drinking kerosene stored in containers such as soft drink bottles.
Almost 70% of Kenyan homes currently rely on wood or charcoal burned in simple stoves for their everyday cooking needs. There are important differences between urban and rural areas, however. In rural homes, wood and charcoal are the primary cooking fuels for 90%, and the pace of change remains slow. The situation is very different among urban homes. Wood or charcoal are now the primary fuels for only about one-quarter, and with recent expansion of the LPG market around half currently use this fuel. Overall, around 25% of Kenyan homes are using LPG as their primary cooking fuel, though many of these will continue to do some cooking with wood or charcoal. Electrification has been a priority for expansion in recent years, but it is still the case that only around one half of homes have a mains connection, and there are large differences between urban and rural areas.
The levels of air pollution in and around homes resulting from the continued use of solid fuels and kerosene are many times higher than those recommended by WHO air quality guidelines. This exposure results in some 15,000 premature deaths per year, the majority from pneumonia in young children. Household air pollution still accounts for almost as many deaths in Kenya as malaria.
Mobilising community health workers
As awareness of this toll on the health of the population has grown, so too have efforts to find more effective ways to accelerate the transition to cleaner, safer and more sustainable energy in the home. The training of community health workers is one such initiative showing considerable promise.
The system of community health workers began in Kenya in 2004 to fill a gap in primary health care, namely engaging with communities to solve health problems. Across the country, Community Health Units were created, each having a population of around 5,000. There are five salaried Community Health Extension Workers and 50 unpaid Community Health Volunteers in every Unit. The volunteers are selected by their own communities on the basis of trust and competence, and each one is responsible for health promotion in around one hundred homes in the neighbourhood.
The community health workers are first trained in basic health promotion knowledge and skills. This is followed by a set of technical modules covering for example water and sanitation, maternal and child health, etc. In response to the burden of disease from household air pollution in the country, the Ministry of Health began in 2019 to develop a new training module.
Dr James Mwitari, formerly at the Ministry of Health and now Dean of the School of Public Health at AMREF International University, leads on this new training initiative. He is clear about the value of training these health workers to help reduce the health burden from household air pollution.
“A community health volunteer is attached to a household, and we have CHWs all over the country”, he says, reflecting on what makes their contribution so unique. “Their presence at the community level, and the fact that they are very good at promoting preventive health services, led us to think that this was the best vehicle for reducing household air pollution.”
Dr Mwitari emphasises that the approach taken with new programme is critical to its success, saying “They must be trained on what to deliver, using the correct methods, and equipped on how to get the messages across – and for that we are developing JobAids, materials using illustrations to communicate key information clearly and simply.”
The content is informed by the recommendations of World Health Organisation’s 2014 Guidelines on household fuel combustion. Avoiding smoke, fuel drying, better ventilation and improved wood stoves are recognised to offer some benefits. But the goal for all homes has to be cooking with clean fuels such as LPG, electricity, bioethanol or biogas, and electric lighting powered by the mains or solar units.
Collaboration with the University of Liverpool
Once plans for the new community health worker programme were agreed, the Kenyan Ministry of Health sought additional technical input and funding to develop and test the training materials. A recently established collaboration with the CLEAN-Air (Africa) Global Health Research Group, led by Professor Dan Pope at the University of Liverpool, was able to provide both the finance and the expertise that the Kenyan team were looking for.
“Our research,” explains Dr Pope, “which has been funded by the UK’s National Institute for Health Research, is investigating ways of accelerating the transition to clean household energy in Kenya, Ghana and Cameroon. A key component is building the capacity of health systems in these countries to inform people about the risks from pollution and what they can do about it.”
Through this collaboration and with some additional funding from WHO, the Liverpool group was able to offer the support that Dr Mwitari’s team needed to test out the training, and to plan for scale-up across all 47 counties in Kenya.
“The hope is that”, Dr Pope added, “the community health workers can make a major contribution to the government’s declared target of majority clean fuel use by 2030. We will then work with our Kenyan colleagues to evaluate the impacts on fuel use, air pollution, affordability, and so on.”
Coronavirus in Africa
In March 2020, Coronavirus gained a foothold in Africa. Community health workers had to focus on protecting the population by reducing the spread of the virus, so the expansion of household air pollution training was put on hold. Kenya, along with most other sub-Saharan African countries, has recorded relatively few infections and deaths when compared to Europe and the Americas. Although testing rates are far lower than in more developed countries, countries such as Kenya so far appear to have avoided a very large number of severe and fatal cases. A number of financial and other support measures have been introduced to protect the most vulnerable people in society. Despite these, however, the impact on the economy is expected to be very substantial with both formal sectors such as tourism as well as the large informal economy being hit badly.
As the epidemic rumbles on across Sub-Saharan Africa, Kenya’s leaders are grappling with the dilemma of whether, and to what extent, they should start relaxing measures designed to protect public health in order to stimulate economic recovery. This situation was articulated by President Uhuru Kenyatta in his address on 6 June 2020:
“Some, including myself, wanted to open up now. That was, and is still, my desire. I want to open up at the earliest opportunity and get the economy going. More so, as Kenya was ranked the third largest economy in Sub-Sahara Africa this week. Others held a contrary opinion. They borrowed from history, scientific models and current experiences the world-over to argue against opening up. With these two viewpoints on the table, I was not dealing with a right and a wrong: I was caught in-between two rights. Those who want to open up are right, and those opposed to opening up are also right. And this clash of two rights placed me on the ‘Horns of a dilemma’.”
Since this pivotal moment, Kenya has opted for what might be termed a very cautious relaxation of restrictions. Thus, internal and international flights have restarted, bars and restaurants are functioning but must close by 9 pm, the nightly curfew now runs from 10 pm to 4 am, and the only internal border crossings allowed are by trucks. In addition, masks must be worn in public and large gatherings, meetings and conferences involving more than 15 people are not permitted. There is evidence that the economic downturn flattened off during the second quarter of 2020 and growth may be recovering.
Investment for recovery: a roadmap from the International Energy Agency
All around the world, national leaders and specialist agencies are turning their attention to what needs to be done in order to stimulate economies and build for the future. Although the energy industry and services of all countries have suffered greatly, a new report from the International Energy Agency, ‘Sustainable Recovery’, argues that investment in this sector can play an important role in recovery.
Six areas of the energy economy are examined: electricity, transport, buildings, fuels, industry and emerging low-carbon technologies. In summary, the findings show that that investment of US$ 1 trillion annually for three years, starting now, could globally deliver around 3.5% additional growth, 9 million jobs and CO2 emissions some 3.5 Gt lower than would otherwise be the case. In respect of clean energy access in Africa, the stark warning is that the current slow rate of transition to clean energy will not keep pace with population growth. Consequently, Sustainable Development Goal 7 will not be met; neither will Target 7.1 which aims for universal access to affordable, reliable and modern energy services by 2030.
To address this shortfall, the Agency proposes investment of US$ 45 billion per year ($135 billion over three years) for electricity access and $5 billion per year (£15 billion over three years) for clean cooking in low-income countries. Around 30-40% of this investment would be expected to come from national governments, the rest from international finance organisations, bilateral donors and private equity. Mobilising private capital is critical to sustained growth and progress, so targeted public investment and policies on regulation and finance that reduce risk and create the right investment environment are recommended.
Optimism tempered by realism
Given the relationship of trust that the community health workers enjoy with the communities and homes they serve, Nancy and Lynn are confident that people will accept what they will be saying about the dangers from wood stoves, kerosene lamps and other traditional practices, and on the need to switch to cleaner and safer alternatives. But they are not so confident that these changes will happen, at least not easily or quickly.
“A challenge might be on the implementation”, says Lynn, “because you find in most cases, we do make promises, but because of, for instance, financial constraints, we are not able to deliver what we have promised to the community members.”
Nancy agrees and emphasises that change will take time: “So, we may not get them to do a turnaround in just a month or so, it will take us time.” She believes that people will be quick to absorb the information, “because they know that we always wish them the best in terms of health, but for implementation, however, we may start with so many intermediate steps.”
The intermediate steps she is talking about include simpler and easily accessible options such as improving kitchen ventilation, avoiding smoke, and buying improved biomass cookstoves from the local market. “But for actual change in the emission sources”, she adds, referring now to the adoption of clean fuels such as LPG, “that will come in with processes that will go gradually”.
These ‘processes’ include not only changing some firmly held perceptions about cost, speed of cooking and safety of a fuel such as LPG, but also the policies and investment needed to make these clean fuels easily available and affordable for everyone, rural as well as urban. The government is committed and has started to make policy changes. In 2019, new regulations restricting how LPG cylinders can be exchanged were introduced and are expected to improve safety. A programme of subsidised LPG cylinders and cookers for low-income homes known as ‘Mwananchi’, which had initially faltered, is due to be relaunched. The new scheme will promote two-burner cookers and newly emerging pay-as-you-go technology linked to the mobile phone network to even out payments and alert marketers to deliver a new cylinder when needed.
Andrew Kamau, Principal Secretary to the State Department of Petroleum, sees this initiative as a catalyst for developing the LPG market: “If we could get 200,000 units into the market and people used to the pay-as-you-go model,” he says, “everybody would want it”.
The Coronavirus pandemic has led to a reduction in the value of oil, and with it a fall in the international price of LPG. For example, during April and May 2020, the price was 40% lower than the 2019 average. This could translate into cheaper LPG refills and shorter payback times for stoves and cylinders – if these savings are passed on to consumers. Some rebound can be expected as oil prices recover, however. Overall, while there have been some encouraging fiscal and policy developments in Kenya over recent years, there is more to do.
Despite this sense of realism about the pace and requirements for change, these community health workers are optimistic. “It is possible”, says Nancy assuredly, “there have been successes with other things, such as oral rehydration for diarrhoea, so this is very much possible”. Lynn nods enthusiastically and is quick to add her own examples: “and also the deliveries – the number of skilled deliveries has increased, and most children have been immunised.”
But will the investments and supportive policies highlighted in ‘Sustainable Recovery’ be forthcoming? If not, the newly-acquired skills and enthusiasm shown by Nancy, Lynn and their colleagues across the country may simply increase expectations and demand for clean energy that is in short supply, not available in local shops, unaffordable for many and sometimes unsafe. This would inevitably create a cycle of mistrust.
A country such as Kenya now faces difficult choices as post Coronavirus recovery policies and investments are planned. The International Energy Agency has provided a roadmap for investments that could mean the difference between the eventual success and failure of the efforts of newly trained community health workers like Nancy and Lynn in their communities.
At the launch of the International Agency’s Report, the Director, Dr Fatih Birol, said, “The plan is not intended to tell governments what they must do. It seeks to show them what they can do.” It remains to be seen whether governments, international finance agencies and private capital will seize these opportunities.